Transcription
Anate wire escalation and parallel wire technique. I think the first part, anate wire EXC, is already done by Dr. Rupali and Dr. UK, so I will focus more on the parallel wire technique. Anyway, something will be repeated. I have nothing to disclose.
Well, for the fellows, if you want to do CTO, you have to understand this slide. If you understand this slide, then you will have a clear concept of CTO. So remember this basic thing: in CTO, you have to connect the proximal true lumen with the distal true lumen, either antegradely or retrogradely. Either by true-to-true lumen by wire escalation method, antegradely or retrogradely, or you can go to the subintima, then again come back to the true lumen after crossing the CTO body. And also retrogradely, you can go subintima and come to the proximal lumen. So the basic mechanism is very clear: you have to connect the proximal true lumen with the distal true lumen, either by wire escalation method or dissection and re-entry method. That's the basic. So if you understand this slide, all the mechanisms fall and sum up into this slide.
Before doing CTO, if you want to do antegrade or retrograde, you have to understand, especially, that the anatomy of the CTO is very important, which has been described by my previous speakers. How is the proximal true lumen? Is it blunt? Is it tapered? Is there a side branch? Is it calcified? So depending on that, if, suppose, if it's a tapered proximal cap, you can probe it with some polymer-jacketed wire like Fielder XT, R-wire, Fielder XTW, a bit harder, or Pilot 50. But if it's stiff, if it's not tapered, it's blunt, then you have to need to penetrate the proximal cap with a harder wire like Gaia second, Gaia third, and even harder; you have to use Confianza Pro 9 or 12.
For CTO recanalization, antegradely by wire escalation method, you have three steps: puncture the proximal cap, traverse the CTO body, puncture the distal cap. These are the three steps for crossing CTO antegradely: proximal cap, traverse the CTO body, distal cap. So I have—then you have to determine the length of the lesion, I’ve say the segment of CTO. If the length is less than 20 mm, we can try antegrade wire escalation method or parallel technique. If more than 20 mm, then dissection and re-entry. Then, distal cap. After reaching here, if it does not go away, you again have to upgrade your wire. And sometimes we only talk about escalation; there is sometimes you have to de-escalate it as well, like you know, when you’re in a war in the Middle East, then sometimes we de-escalate it. So like that, after crossing this proximal CTO body, if you feel that there is less tissue resistance, loose atheromatous tissue, then you can change your CTO harder wire like Gaia second or Confianza Pro to Fielder X-wire because there are some microchannels; it passes very fast distally. So not only escalate, sometimes de-escalate your wire as well.
So there are different algorithms; I’m showing it’s one algorithm. And the key point of doing CTO, especially antegrade, even if there is a collateral channel, you have to give dual injection. And if there’s an ambiguous proximal cap—not if there’s a poor—if appropriate, this is for retrograde, not for antegrade. So if these two answers are no, then you have to measure the lesion length. If it’s less than 20 mm, then my topic is antegrade wiring by either antegrade wire escalation or de-escalation method or parallel technique. So it is a mostly used strategy in CTO PCI, though we talk about retrograde very often, but retrograde is very cumbersome and comes with complications, and you have to cross the algorithm.
The question was, how long should I try this? When you see that your wire is buckling or your wire is not in the intimal space, is going to the subintima, then it’s time to change your technique or wire. So integrated approach to true lumen: either single wire manipulation by wire escalation or dissection method, then parallel wire technique, and sometimes we do IAS-guided wiring as well. So while doing the wire shaping for CTO, it’s very important. You can have two bends, like one or two mm, 30° bend, and then after four millimeters, there could be a 60 mm bend. This is the bend we often use, but sometimes, to penetrate the proximal hard cap or distal hard cap, you can give this almost 60 to 90° bend after two to three mm with a harder wire. These are the two ideal wire shapes for CTO crossing and penetrating the hard cap.
So what are the basics of antegrade wire escalation? Escalation of wire tip to cross with microcatheter support. Always take a microcatheter; don’t cross any CTO without a microcatheter. Understanding the anatomy of CTO details, wire selection, whether it’s tortuous, whether it is straight, or whether there is calcium or not, and following cap penetration. Medium-weight polymer-jacketed wire can be used. Escalation and de-escalation also is very important by your feel of the CTO resistance. If it’s—if it is not harder, then go for escalation. If it feels softer, then you can de-escalate to polymer-jacketed wire. And always confirm wire position with orthogonal views and retrograde injections, and try to wire inter-luminal CTO by—in the inter-luminal method before entering distal—then you will not lose the side branches. So usually we start with a slippery wire like Fielder XTR, R-XT, Whisper, Pilot. Then if it fails, then we upgrade it, escalate it to Miracle 3 or Ultimate Bro or Gaia first, and then we go for Gaia second, third. Now Gaia two, next Gaia three, next. And even then, if you can fail to, then you can escalate to steerable wire, taper Confianza Pro 9 or 12. There are different algorithms and different wires and their properties; I’ve already explained by my previous speakers now. And there’s a picture like taper; you can see Fielder XTR; we have some loose channels here. Is XTU, then Gaia second, then Gaia third, then Confianza Pro.
Parallel technique: if one wire goes to false lumen, then we keep it there and take another wire, which should be harder and a bit more bent, and then by the guidance of the first wire, we can take it to the distal lumen and penetrate the distal hard cap. So in parallel technique basics: when the first wire goes to the space, keep it there and take the second wire, and don’t take out the first wire, because then you lose the information already gained, and always it will prevent the second wire to go into the false lumen, and it also helps to modify vessel architecture and status of vessels. The second wire should be stiffer than the first wire and with more curve at a steep angle. Always check the relative position of the wire in different orthogonal views.
There’s a case example. You can see it’s an RCS CTO, but you can see there’s some microchannels, though we’re not sure which one to poke, but you have to take different views to see the correct microchannel. And then we took, by the help of microcatheter Fielder XTW, by sliding method, and it passed easily. So CTO done by five minutes, putting stent. And this is the last picture. Same patient, same patient. You can see there is retrograde collateral to the left circumflex. So double catheter, and there is the occlusion of approximately 20 mm. So again, different orthogonal view to see the course of vessels. Now I again probed with—tried with first with wire escalation method; I tried with Fielder XT wire, but I failed to penetrate the proximal cap. So then tried harder wire, Confianza Pro 9, with microcatheter support, but unfortunately it went to false lumen in the diagonal branch. So he pulled it out, tried a different path, again into the false lumen in the distal true vessels. So you can see the wire is out of the vessel architecture distally. Then went for parallel wire technique. The second wire was Confianza Pro 12. So keeping the first wire in the false lumen, tried the Confianza Pro 12 wire; it acts as a guide. So this is parallel technique. And then inch by inch I proceeded and almost reached the distal cap, but did not puncture. You shouldn’t puncture. So take two different orthogonal views, then I directed my wire tip to the distal true vessels and punctured. And after passing that lesion, you must change the dilation catheter to BMW because it can perforate. And this is the last picture after putting the stent. Okay, not stenting, sorry. I think time is up. So that’s it. I think only a few slides left. Can you just—no, I’m done. I’m done. I’m done. Just take a message. Just take a message. Please show the take-home message. Yeah. Always try to double puncture, introduce double catheter, and always visualize the distal vessel for CTO intervention. If there is collateral, first try to probe with microchannel with CTO with slippery wire first. If you fail, then go for harder wire like Gaia, Gaia next, or Confianza Pro. If the first wire goes to false lumen, keep it there; don’t panic, and try to take another second, harder wire for parallel technique. And never lose hope; keep the patient safety first. Thank you. That’s it. Thank you. Thank you very much. There is a question from—Thank you very much for a nice presentation and lecture also. I have a question. In parallel technics, you show that is there is a CTO, so both wires should covered by—by microcatheter, so two microcatheters inside there. Is the—in one wire you place in a false lumen, then you try another. So both are—no, no, no, no. There are three options. One is if one wire goes to false lumen, what I did in this case, I keep the wire there, I take the microcatheter out, then I take the second wire with the microcatheter. One second, you can use a double-lumen catheter, like the Suzuki double-lumen catheter. You can take the—what the first wire—and there’s another hole in that wire, so you can take the second, harder wire through the double catheter, to single catheter, but two lumens. And third is what you have told; sometimes we can take two microcatheters, two wires, and this is called SE technique. This is also another parallel technique, but to make it simple, keep the first wire there, take the microcatheter out, and take the second wire by microcatheter. Thank you.
Yeah, a parallel wire is a very good technique; however, it depends also on anatomy, because if you have a very tortuous artery, then wire might enlarge dissection or produce more dissection. So I think this could be kept in mind. You should know the anatomy before selecting any technique to do. Yeah. I totally agree with you. For doing CTO, two things are important: one is the anatomy of the CTO, which is already told by my previous speakers, the proximal cap, distal cap, and course of the CTO, and second is you feel while you are passing the wire. How do you feel? So when you feel resistance, buckling, then it’s time to change your wire. But even, even you are not trying to cross the lumen, there’s buckling, and if it is out of the vessel structures, and even you’re trying, then you’re making the dissection more, and it can cause intramural hematoma and collapse the distal lumen as well. Thank you. Thank you for nice deliberation, and you are a CTO guy also. So reading—I always learned from you, medicine, surgery, CTO. You’re my first boy. So what about the knuckle wire? Which one is your choice of wire when you like to do intentional knuckle, or accidentally it becomes knuckle, then you push through the subintima and ultimately goes into the lumen? Which one is the best wire do you prefer to produce the knuckle? Wire knuckle wire is a dissection and re-entry method. So usually we use polymer-jacketed wire; either Fielder XR wire is my favorite one, Fielder XTR. I can use Pilot 50 or 100 or maybe sometimes Whisper as well. But now there is a dedicated wire from the Asahi Intaka; this is Gladius. So this is only for knuckle; they made Gladius. But in knuckling also, you use through microcatheter. Yes, of course. Thank you.