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Combined Use of Contact wire i technique t h i and d Parallel wire technique for Complex CTO Nae Hee Lee. MD. PhD. Soonchunhyang University Hospital, Korea Evolution of CTO-PCI • • • • Contralateral C l l angiography i h Dedicated hard CTO wires Two wires technique Retrograde approach Evolution of CTO-PCI • • • • Contralateral C l l angiography i h Dedicated hard CTO wires Two wires technique Retrograde approach Parallel Wire Technique Parallel wire technique, which is a typical technique of two wires technique, is very useful when 1st wire get into the subintima and make a false lumen P Parallel ll l Wire Wi Technique T h i Selection S l ti off 2nd wire i iis d dependent d t on th the llesion i characteristics h t i ti or/and operator preference (I usually use Conquest pro series). Example of parallel wire technique M/72, pLAD / pLCX CTOs Conquest pro Conquest pro Conquest pro 12 Conquest pro Miracle 3 In parallel wire technique, delivery of 2nd wire to the CTO site is sometimes cumbersome or difficult Double lumen MC (Crusade MC) Guide wires movement through the “double layer lumen” Double lumen (Crusade) ( ) Microcatheter Parallel wire technique See-saw techniques • Crusade can be delivered to target site along the 1st wire like the monorail balloon catheter, catheter and then 2nd wire can be delivered to target site through the side hole. Æ Make it possible to deliver the 2nd wire easily regardless of proximal lesion anatomy • Because both 2nd and 1st wires are supported by this MC, alternate use of both wires is possible with easily changing their roles as a marker of the wrong plane Æ Similar concept to See-Saw wire technique Example of double lumen catheter M/64, pRCA CTO, prior failed case Very difficult to deliver the wire to the CTO site AL-1 short tip 7 Fr JR 4 short tip Anchor balloon technique Parallel wire technique with Crusade mc Distal port P Proximal i l portt 1st wire 2nd wire P ti t Summary Patient S Patient : 61-yr-old 61 yr old male HTN, DM under medications EKG cardiac enzyme: Non EKG, Non-specific specific finding Treadmill test: positive finding at stage II E h Echocardiography: di h N Non-specific ifi fi finding di D stable Dx: bl angina i Baseline Angiography Baseline Angiography H How should h ld we approach h this thi case? ? • Bad signs a) Can’t find any stump at any projection b) Two T big bi side id b branch h arteries t i att proximal i l occlusion l i site it ÆTrifurcation stumpless CTO c) Collateral connections for retrograde approach ÆPossible, but not so good • Good signs a) Relatively straight mid-LAD CTO lesion b) Not so long length of occlusion body c) Definite calcification is not seen IVUS examination 8-Fr. Fr EBU, EBU 3 3.75 75 guiding catheter Filder--FC wire to Filder septal branch IVUS examination * CTO proximal entry point Fielder FC IVUS guided wire technique After finding the entry point of proximal cap by IVUS, we attempted to enter the CTO body under the IVUS guiding B t Wire But, Wi repeatedly t dl entered t d the th 1st septal t lb branch h Therefore, we removed the IVUS catheter with leaving the Therefore Fielder FC wire on septal branch, and then we tried to penetrate the proximal cap of CTO with variable wires.(fielder XT, Miracle 3g & 12g, Conquest Pro) with the support of Crusade double lumen microcatheter. However, any wire couldn’t get into the CTO proximal cap and all of them repeatedly slipped into the septal branch (We couldn’t manipulate wires to intended direction due to acute angle of entry point). What shall we do? Contact wire Technique Fielder FC in septal branch was exchanged for Miracle 3g, and then Miracle 12g was tried again to puncture the proximal CTO cap. Crusade MC Miracle 3 in septal Miracle 12 2 stiff ff hydrophobic wires could create contact resistance, which could make a pivot to desired direction However, punctured M12 repeatedly got into the false lumen in CTO body. Switching g to Retrograde g Approach? pp However, there was a possibility that the M12 altered the vessel axis,, which could make handling g of 2nd wire easier. Parallel wire technique q Crusade MC Crusade MC Miracle 12 Miracle 3 in septal Conquest pro Miracle 12 Septal M3 was removed and C-pro was used as a 2nd wire 2nd Parallel P ll l wire i ttechnique h i C Crusade d MC 1st Conquest pro C Crusade d MC nd Miracle 212 Conquest q pro p Conquest pro Fi l Angiography Final A i h How could we get over thi stumpless this t l big bi side id branch CTO? Another Conquest Pro Conquest Pro 2 Parallel wire 2nd Hydrophobic wire nd d 1st diagonal Technique (Miracle 12) 1st Hydrophobic wire (Miracle 3) LAD CTO Create 1st Parallel wire Resistance Technique (Contact wire Technique) 1st septal Message at home • Various kinds of double wire technique play a important role for increasing the success rate of complex CTO-PCI. • Contact wire technique, which takes advantage of wire bias ( (contact resistance), ), can be used for stumpless p branching g point CTO • If the th 1st wire i iis iin ttrouble, bl you should h ld nott h hesitate it t tto early l use the parallel wire technique before the false lumen compress the collateral flow. • Double lumen MC, which make wire exchange easier and act lik ttwo microcatheters, like i th t is i useful f l tool t l for f double d bl wire i ttechnique. h i
