10:05 Gershlick - The kit

Department Academic Cardiology
Tony Gershlick
Professor of Interventional Cardiology
University Hospitals of Leicester UK
Madrid 2014
Chronic Total Occlusions :
The kit
National Institute for Health Research,
Leicester Cardiovascular Biomedical
Research Unit

Methods
• Analysis of the UK Central Cardiac Audit
Database
• Procedures between Jan 1st 2005 – Dec 31st
2009
• 326 398 PCI procedures
• 15 492 elective CTO procedures on 13 443
patients
• Mortality data from the Medical Research
Information Service (MRIS)

Successful revascularisation is associated with reduced mortality

Pandora's box is an artifact in Greek mythology, taken from the myth of
Pandora's creation in Hesiod's Works and Days.
The "box" contained all the evils of the world.
Impelled by her curiosity (given to her by the gods ), Pandora opened it
and all evil contained therein escaped and spread over the earth. She
hastened to close the container, but the whole contents had escaped;

Techniques for chronic total occlusion (CTO) recanalisation.
Smith E J et al. Heart doi:10.1136/heartjnl-2013-304521
Copyright © BMJ Publishing Group Ltd & British Cardiovascular Society. All rights reserved.

Date of download:
11/10/2013
Copyright © The American College of Cardiology.
All rights reserved.
From: A Novel Modification of the Retrograde Approach for the Recanalization of Chronic Total Occlusion of
the Coronary Arteries: Intravascular Ultrasound-Guided Reverse Controlled Antegrade and Retrograde
Tracking
J Am Coll Cardiol Intv. 2010;3(2):155-164. doi:10.1016/j.jcin.2009.10.030
Schematic Diagram Showing Use of Snare Wire
(A to D) Showing the use of snare wire to keep the subintimal space open after antegrade balloon dilation and intravascular
ultrasound (IVUS) confirmation; (E) retrograde wire crossed to the antegrade true lumen. Right arrowhead (▶) indicates distal lumen
and left arrowhead (◀) indicates proximal lumen.
Figure Legend:

ACT every 30 mins
>> 250 secs
No ReoPro till end
300

The hybrid algorithm for chronic total occlusion percutaneous coronary intervention (CTO
PCI).
Copyright © BMJ Publishing Group Ltd & British Cardiovascular Society. All rights reserved.

Fielder
FC
Fielder SION SION
blue
XT XT-R ULTIMATE
blos3
1mm
Shaping of the Wire Tip

- Beyond Fielder XT -
• Anti kinking structure
• Higher torque performance with W core
Tip load
XT-A = 1.0g XT-R = 0.6g

PTFE Coat
・ Length over all ; 1900
・Coil length ; 160
・Radio paque ; 160
Unit ; (mm)
straigh
t
taper
3010
0.014Inch
Urethan + Hydrophilic Polymer
Coat
0.009Inch
Fielder XT

• Uni-body core with long, smooth taper from support
region to tip
• Hydrophilic-coated, polymer sleeve and tip
• Intermediate wire with slightly stiffer tip
• Crossing performance of polymer tip with visibility of
spring tip
PT Graphix™ Guide Wire

0.014Inch
Hydrophilic Polymer Coat
PTFE Coat
Rop
e
Unit ; (mm)
・ Length over all ; 1800
・Coil length ; 280
・Radio paque ; 30
Actone
Sion

Abbott –Progress Wires
40-80-120-140-200

0.014“
Hydrophilic Coating
17cm Radiopaque Spring Coil
0.008“
Stainless Steel Core PTFE Coating
0.014“
Confianza Pro 8-20
Tip Load: 20G
Radiopacity length: 17cm
Outside Diameter: 0.014inch
Tip outside Diameter: 0.008inch
*Product not available in Europe

Micro cone. enables easy creation of
an entry route into hard fibrous cap.
almost needle like. The tip loads are
low, 1.7 on the first, 3.5 on the second
and 4.5 on the third but have the
penetrative power of the higher tip
miracles.
Gaia also is part of the new Sion Tecc
range so has 1 - 1 torque
The shaft thickness are different from
1 st through to 3 rd and the tapers and
tip diameter differ on each wire.
The Gaia allows you to steer your way
through a CTO using rotational
deflection, you can change your
direction if you get stuck and try a
different path, the wire is designed to
stay in the true lumen.

TEIS
Improve wire pushabilityConcentrate rotating force
for better wire control
Superior device passage for the next option
1. 2.
Clinical benefits of Finecross® MG
3.

Micro-catheter for wire
support & exchange

Trapping balloon
Wire supported by micro-
catheter
Need to exchange for a
balloon
20 atmos

ewire Crossing – Unique features demonstration
1. NHancer CTO access
The presence of micro channels has proven to be a
significant factor of CTO crossing success. If these are
tip to tip > 1 (cm)
tip to tip ̴ 4 (mm)
tip to tip ̴ 2 (mm)
sis demonstrate that
O closure are more to
l than to the vessel
ry would be ideal
ssel perforation/
men
lization of micro
lcification on the route
aping analysis of CTO
ically a wire take-off
vessel diameter at
l guidewire tip
at vessel wall area.
p take –off (2.5 mm)
All illustrations are on scale. Vessel is 2.5 (mm)
p take –off (2.3 mm)
NHancer enables on angio tip shaping
which increase the ability to seek CTO
entry more to the center of the CTO
– Revolutionize Primary Guidewire Cross
2. Adaptive force transmission
Conventional support catheters back-out
when backup support is needed
Due to the unique locking feature the
NHancer cannot back out and provides
more support to the guidewire tip.
The improved force transmission
increases the capability of the wire to
penetrate and cross the CTO.
Escalating wire selection towards stiffer
tip configurations, higher tip load, is
3. Smallest shaft profile
The NHancer’s small shaft
profile, combined with the
NDurance hydrophilic
coating reduces the need
to dilate vulnerable septals
and eases septal crossing
during retrograde
approach

Specialty Catheter designed for guide wire support and exchange
The Tornus specialty catheter, with its braided stainless steel
construction, is designed to enable guide wire exchange and support.
Braided Stainless Steel Catheter
for outstanding support and pushability
1mm Distal Radiopaque Marker
for easy visualization of the distal tip
Tapered Tip
designed to facilitate access to challenging lesions
Asahi Tornus ®

Optimizing Circular Ring Arrays for
Forward-Looking IVUS Imaging : Tekes
2011

C7 Dragonfly™ Intravascular Imaging
Catheter
•Non-occlusive flush action
eliminates the need for
occlusion balloon
•Extreme Resolution imaging
based on OCT technology
•Low-profile minirail tip for fast
placement
•Hydrophilic coating reduces
drag
•Dual marker bands for precise
positioning
•Compatible with standard
0.014” steerable guidewires
•Imaging speed up to 25 mm

Tracks via FAST SPIN technique
•Spin should reduce push required
•Highly torqueable shaft
0.014" guidewire
compatible (OTW)
Atraumatic 3F
rounded distal tip
2.3F shaft profile
The CrossBoss™ CTO Catheter

Balloons: Falcon CTO Balloon RX/OTW 1.00mm
Falcon CTO is a small diameter 1.00mm designed for
Chronic Total Occlusions.
Technological Innovations
 Low entry profile (0.016”) facilitates lesion
access
 Tapered 4.5mm tip crosses the lesion first
 Up to 15 atm RBP and a variety of lengths offer
many treatment options
Proprietary Shaft
 Shaft maintains efficient transmission of push
 Tack-welded inner tube enhances trackability
and pushability
4.5-mm Elongated Tip
 Tapered tip navigates tortuous anatomy
 Flexible design enhances steerability
Low-entry profile tip (0.016”) provides excellent tip-to-wire transition
4.5-mm tip crosses the lesion prior to balloon
1.35 mm at 15 atm provides access for a wide range of treatment options
No accordion effects while
crossing and recrossing
arteries
Test data on file at Medtronic Inc. Bench test results may not be indicative of clinical results
Crossing Semi-Compliant

Falcon CTO is a small diameter 1.00mm designed
for Chronic Total Occlusions.
Product Specifications
Catheter design: RX OTW
Balloon material: Flexitec PF
Balloon coating: LFC hydrophilic coating
Balloon marker: 1 or 2 swaged (zero profile)
platinum iridium
Shaft diameter: OTW: distal 2.2 F; proximal 3.3 F
RX: distal 2.2 F; proximal 2.0 F
Usable shaft length: 145 cm and 160 cm
Maximum
recommended
guidewire: 0.014” (0.36 mm)
Low-entry profile tip (0.016”) provides excellent tip-to-wire transition
4.5-mm tip crosses the lesion prior to balloon
1.35 mm at 15 atm provides access for a wide range of treatment options
DCR
this
slide
Balloons: Falcon CTO Balloon RX/OTW 1.00mmCrossing

Getting the retro-grade wire into the antegrade
Guide catheter

CPS Venture® Wire Control
Catheter

Can knowing (and being expert with )
the available kit make a difference ?

• Observational study
• 483 participants with CTO
• Selection of patients based on symptomatic angina, evidence
of viability and ischaemia in CTO territory (CMR, MPS, exercise
stress echo)
• Classification of lesion complexity using J-CTO score
• Success determined within 2 time periods:
- Period 1: April 2003 – October 2008
- Period 2: October 2008 – May 2012
Sysreloudis D et al. Heart 2013; 99: 474-479

Technique Period 1 Period 2
Corsair microcatheter for antegrade/retrograde
support
No Yes
7F guiding cathtetrs allowing trapping balloon use No Yes
Reverse CART and wire escalation, retrograde
knuckled wire for controlled subintimal dissection
No Yes
7-8Fr Antegrade catheters Rare Routine
Anchoring balloon Rare Routine
Long femoral sheath Rare Frequent
Contralateral injection Routine Routine
Parallel wire technique Frequent Frequent
Stingray Catheter for distal re-entry No Rare (bail-out if
no retrograde
option present)
Wire “sliding “ with tapered soft wire Rare Routine as start
of an antegrade
approach

Lesion complexity characteristics

Success rates by procedural complexity

Keep it simple if possible
Become familiar with particular kit and use frequently
Be aware of device options
Don’t get carried away
A series of escalating wires
IVUS
Micro-catheter /Corsaire
Guideliner/Guidezilla

10:05 Gershlick - The kit

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