Session 3 - Retrograde approach – EUROCTO algorithm
- 1. Retrograde approach: Euro CTO algorithm Chair of Cardiology, Department of PROMISE, University of Palermo, Italy and Royal Brompton Hospital & Harefield NHS FT, London, England Alfredo R. Galassi MD, FESC, FACC, FSCAI
- 2. I, Alfredo R Galassi DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation Disclosure Statement of Financial Interest
- 3. Surmely JF, Katoh O, Tsuchikane E et al. CCI 2007
- 4. Sianos et al. EuroIntervention 2008
- 5. There are CTO’s and CTO’s J-CTO score = 0 J-CTO score = 3-4 can be attempted by non-CTO operator Should not be attempted by non- CTO operator
- 6. RECALL Morino et al. JACC Intv 2011 J-CTO score sheet: predicting complexity
- 7. Vemmou et al, Eurointervention 2020
- 8. Retro is primarily used in more complex cases RECHARGE CTO Registry Maeremans et al, JACC 2016 >3 times
- 9. Technical success and crossing strategy use according to J-CTO Score from the PROGRESS CTO Registry Tajti et al, JACC Intv 2018
- 10. Case selection guided by the J-CTO score and operator experience Harding SA and Tsuchikane E et al, JACC Intv 2017
- 11. Brilakis et al, J Am Coll Cardiol Intv 2015 Success rates and operator volumes Success rate and operator volume 53 62 75 0 10 20 30 40 50 60 70 80 <5 CTO/yr 5-10 CTO/yr >10 CTO/yr MACE rate and operator volume
- 12. Course Directors Nicolaus Reifart Main Taunus Kliniken Bad Soden, Germany Gerald S. Werner Medizinische Klinik Klinikum Darmstadt Darmstadt, Germany Co-Directors Alfredo R. Galassi Ferrarotto Hospital University of Catania Catania, Italy George Sianos AHEPA University Hospital Thessaloniki, Greece Hans Bonnier University Hospital Brussels Brussels, Belgium Galassi AR et al, on behalf of the Euro CTO Club
- 13. Harding et al, JACC Intv 2017 The Asia Pacific CTO Club Algorithm
- 14. Tanaka et al, JACC 2019 A novel algorithm for treating Coronary Chronic Total Occlusions
- 15. Frequency distribution of successful guidewire crossing time for each CTO-PCI strategy Tanaka et al, JACC 2019 23 mins 60 mins 126 mins 107 mins
- 16. The North American Hybrid Algorithm Brilakis et al, Circulation 2019
- 17. Maeremans et al, JACC 2016 The Hybrid Algorithm– RECHARGE Registry
- 18. UK Hybrid CTO Registry RDR is primarily used in more complex cases Wilson et al, Heart 2016
- 19. The Euro CTO Algorithm Galassi et al, EuroIntervention 2019
- 21. MICROCATHETER POSITIONING & STRATEGY
- 22. SIZE COMPARISON Product Tip Entry profile Distal shaft OD Proximal shaft OD ASAHI Corsair Pro 0.42mm (1.3Fr) 0.87mm (2.6 Fr) 0.93mm (2.8 Fr) ASAHI Caravel 0.48mm (1.4Fr) 0.62mm (1.9 Fr) 0.85mm (2.6 Fr) ASAHI Corsair Pro XS 0.44mm (1.3Fr) 0.71mm (2.1 Fr) 0.95mm (2.9 Fr) Competitor A * 0.53mm (1.6Fr) 0.74mm (2.2 Fr) 0.97mm (2.9 Fr) Proximal shaft OD O.D. 0.95 mm (2.9 Fr) Distal shaft OD O.D. 0.71 mm (2.1 Fr) Entry profile 0.44mm (1.3Fr) Longer and more durable hydrophilic coating for improved lubricity performance
- 23. Suggested microcatheters Retrograde CTO Septal Tracking Main characteristics required Torqueability Crossability ASAHI MICROCATHETERS POSITIONING (when flexibility and more support are needed)Support (when lower profile is needed)
- 24. Suggested microcatheters Retrograde CTO Epicardial Tracking Main characteristics required Low profile Trackability ASAHI MICROCATHETERS POSITIONING (when lower profile is needed)
- 26. Sion Sionblack XT-R Suoh 03 Septal CC Standard Applicable Limited Applicable Epicardial CC Applicable Limited Very Limited Standard Atrial or marginal Applicable Limited Very Limited Standard CC 1 or 2 Standard Applicable Applicable Applicable CC 0 Applicable Limited Applicable Standard Unvisualized CC Limited ? Limited Applicable Corkscrew Limited Limited Risk of perforation Applicable Rigid epicardial or atrial or marginal Limited Limited Risk of injury Applicable Dedicated guidewires for collateral crossing
- 28. XTRAND Coil Micro-cone Tip ACT ONE High torque performance while ensuring tip flexibility High penetration efficacy Anti trapping feature to avoid coil damage Features of ASAHI GAIA NEXT for retrograde wire escalation
- 29. By use of the XTRAND Coil, ASAHI Gaia Next series shows higher torque force This helps to enable more precise manipulation of the tip in occluded lesions which were previously difficult Test Method： Measure the maximum power to torque gage when rotate the guide wire in CCW direction while fixing the tip of GW Torque (mN・m) Torque Force Test of ASAHI GAIA NEXT
- 30. Directed Reverse CART technique
- 31. Directed Reverse CART technique
- 32. Conventional “Directed” “Extended” Extent of the intimal/ subintimal space Prior CTO wiring Knuckle wire technique (Antegrade or retrograde) Antegrade balloon size Retrograde guidewire IVUS-guidance Suitable cases Unsuitable cases Within the CTO segment Within the CTO segment Beyond the CTO segment (proximal or distal) Antegrade or retrograde Antegrade or retrogradeAntegrade Suitable SuitableUnsuitable Large LargeSmall Low penetration force, controllable guidewire (high penetration force guidewire in Pattern D of Figure 2.) Gaia -series of guidewires (Asahi Intecc) Proximal; low penetration force, controllable guidewire, distal; high penetration force guidewire Yes, if difficulty in achieving reverse CART No, (move on to IVUS-guided reverse CART if "directed" reverse CART is unsuccessful) Yes, if difficulty in achieving reverse CART or there is a large side branch close to the proximal cap All CTOs which are not suitable for "directed" reverse CART Short CTOs with clear proximal cap and occlusion course without heavy calcification, and severe tortuosity CTOs in which antegrade or retrograde cap penetration is not possible None CTOs with proximal cap and/ or CTO course ambiguity, heavy calcification, and severe tortuosity, short occlusion length ( < 15 mm ), poor retrograde wire control CTOs with a large side branch close to the proximal or distal cap Figure 1. Overview of the 3 subtypes of the reverse CART techniques. Matsuno S et al, Eurointervention 2018 Different type of Reverse CART technique
- 33. Externalization in antegrade Guideliner
- 35. Course Directors Nicolaus Reifart Main Taunus Kliniken Bad Soden, Germany Gerald S. Werner Medizinische Klinik Klinikum Darmstadt Darmstadt, Germany Co-Directors Alfredo R. Galassi Ferrarotto Hospital University of Catania Catania, Italy George Sianos AHEPA University Hospital Thessaloniki, Greece Hans Bonnier University Hospital Brussels Brussels, Belgium Antegrade RetrogradeOverall
- 36. Industry Assembly 6th European Live Summit on Retrograde CTO Revascularization April 28-29, 2017 - Zurich, Switzerland Course Directors Course Vice Director & Coordinator Alfredo R. Galassi , MD, FACC, FESC Oliver Gaemperli, MD, FESC Thomas F. Luscher, MD, FACC, FESC George Sianos, MD, PhD, FESC Full Members Associate Members Antegrade/Retrograde Procedures 0% 20% 40% 60% 80% 100% 90 88.5 89.5 86 77 71 72.4 64.9 67.2 64.8 66.6 60.2 10 11.5 10.5 14 23 29 27.6 35.1 32.8 35.2 33.4 39.8 Antegrade Retrograde± Antegrade 0% 20% 40% 60% 80% 100% 76.3 76.7 76 73.3 88.6 23.7 23.3 24 26.7 11.4
- 37. Industry Assembly 6th European Live Summit on Retrograde CTO Revascularization April 28-29, 2017 - Zurich, Switzerland Course Directors Course Vice Director & Coordinator Alfredo R. Galassi , MD, FACC, FESC Oliver Gaemperli, MD, FESC Thomas F. Luscher, MD, FACC, FESC George Sianos, MD, PhD, FESC Full Members Associate Members Angiographic Success 0 20 40 60 80 100 85.5 86.5 88.1 87.6 87.8 90.3 87 89 89 92 90 90.1 73.6 64.2 77.1 76.5 77.8 79.582.2 83.3 81.2 83.682.9 80.3 Antegrade Retrograde 0 20 40 60 80 100 84.8 91.3 91.1 90.9 87.8 78.1 81.2 73.8 74 77.8
- 38. 13.1 11.8 9.1 10.6 9.9 9.9 26 19.8 19.6 19.3 17.8 20.1 26.7 27.1 30 26.9 27.8 25.8 22.3 24.9 24.8 26.3 27 25.7 9.5 13.4 13.9 13.7 14.6 15.9 2.4 3 2.7 3.1 3 2.6 0% 20% 40% 60% 80% 100% 2014 2015 2016 2017 2018 2019 0 1 2 3 4 5 J-CTO score during years 34,2 44,2
- 39. Industry Assembly 6th European Live Summit on Retrograde CTO Revascularization April 28-29, 2017 - Zurich, Switzerland Course Directors Course Vice Director & Coordinator Alfredo R. Galassi , MD, FACC, FESC Oliver Gaemperli, MD, FESC Thomas F. Luscher, MD, FACC, FESC George Sianos, MD, PhD, FESC Full Members Associate Members 0 1 2 3 4 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 0 0.5 1 1.5 2 2.5 3 3.5 4 2015 2016 2017 2018 2019 Complications
- 40. Conclusions1 Retrograde procedures is primarily used in more complex cases Retrograde procedures are perfomed with or by an experienced operator (among retrograde operators those with more experience - >100 cases per year - shows stable success with increased JCTO complexity) Suggestion to use primary retrograde approach if there are: • Proximal cap ambiguity • Poor distal vessel quality • Bifurcation at distal cap • Appropriate interventional collaterals • Lesion lenght >20 mm • Severe calcifications • Ambiguous vessel course
- 41. Conclusions 2 No of retrograde CTO PCI increased significantly during last years ~40% Retrograde overall success ~80% (but more complex procedures treated during last 5 years) Retrograde as first-line strategy more widespread used than retrograde after antegrade failure New micros and new wires have made retrograde approach less cumbersome Septal collaterals still the preferred use (~60%); however epicardial collaterals used increased up to ~30% If RWE is not feasible, Knuckle Wire Technique might be used, but please try first Directed Reverse CART, secondly Conventional Reverse CART and finally Extended Reverse CART Severe complications ~ 0.5% (with the only exception of perforations which are still <3.0%)
- 42. SAVE THE DATE September 10-11, 2021 MILAN , ITALY
- 43. Thank You For Your Attention www.alfredogalassi.com
- 44. Thank You For Your Attention www.alfredogalassi.com