Antegrade Dissection Re-Entry Step

by Step
Dr Julian Strange FRCP MD
Antegrade Wire Escalation
Antegrade Wire Escalation

Antegrade
Dissection Re-entry
Antegrade Wire Escalation

Antegrade
Dissection Re-entry

Retrograde
Wire escalation
Antegrade Wire Escalation
Retrograde Dissection Re-entry

Antegrade
Dissection Re-entry

Retrograde
Wire escalation
Antegrade Wire Escalation
Retrograde Dissection Re-entry

Antegrade
Dissection Re-entry

Retrograde
Wire escalation
Strategies Lesion Length <20mm

Hybrid video registry, Daniels D et al. presented TCT 2013

Strategies Lesion Length >20mm

Hybrid video registry, Daniels D et al. presented TCT 2013

 J-CTO Score

Length of CTO Calcium >45 Degree Bends Blunt Prox Cap Prior Failure

AWE DRE
High

Applicability

Low
AWE is decreasingly successful with increasing
complexity
ADR is increasingly relevant with increasing
complexity
RWE / RDR is increasingly relevant with increasing
complexity
 Strategies Used
Initial Final

AWE
ADR
RW
RDR

AWE: antegrade wire escalation ADR: antegrade dissection reentry

RW: retrograde wiring RDR: retrograde dissection reentry
Antegrade Dissection Re-entry (24%)

Re-entry

Crossboss / Stingray 73%

(SR 80%: CB T–T 20%)
Wire based / LAST 23%
STAR 4%
1. Which lesions are suitable for ADR?
 Five Questions

1.Is the Proximal cap ambiguous or not?

2.Lesion length < or > 20mm

3.Quality of the distal target: Landing zone

4.Are there any major bifurcations/sidebranches

5.Own skillset and quality of retro-collaterals

Subintimal
rationale:
inevitability of
Sub-intimal access
Subintimal
rationale:
inevitability of
Sub-intimal access

Tsujita et al. JACC Intv 2009

Subintimal
rationale:
safety

Tsujita et al. JACC Intv 2009

Subintimal rationale: safety
Subintimal rationale: safety
 Adventitia is tough & elastic
Published Data from Human Tissues

Subintimal
Adventitial layer on average is about three rationale:
times higher ultimate tensile stress than the physiology
related media and intima

1600
1400
1200
1000
Intima
800
Media
600 Adventitia
400
200
0
Radial Direction Longitudinal Direction

Am J Physiol Heart Circ Physiol. 2005 Nov;289(5):H2048-58.

Epub 2005 Jul 8.
Subintimal rationale: efficiency
GW Success <30 mins %
Subintimal rationale: efficiency
 Knuckle wire is not new

• Subintimal Tracking And Re entry

(STAR) - Colombo et al

• Limited Antegrade Subintimal Tracking

(LAST) -Thompson et al

• Bridgepoint Medical Systems

Crossboss and Stingray kit (BPM)
What equipment is needed for reliable
Antegrade Dissection Re-entry?
 ADR: Crossboss

Central
lumen is
flushed
ADR: Stingray balloon and wire
Exchange Crossboss for Stingray
Balloon
 Standard
case
walkthrough:

Tapered prox cap: 0

CTO length > 20mm: 1
No Ca+: 0
No tortuosity: 0
Previous failure: 1

JCTO score 2
Stingray puncture
“Stick & swap”
 Stick & Swap
• The Stingray wire is
adapted for penetration
• Can be hazardous in
small, tortuous distal
vessels
• Fenestrate the artery
and follow with a
jacketed wire Wire: Pilot 200

4.7g Polymer Jacket

 Stick & Swap
• Exit the appropriate
port
• Separation from
Stingray balloon
• Wire should pass freely
• Can take time
Advance microcatheter &
change to workhorse wire
Wire: Pilot 200

Wire: Spring coil workhorse wire

Complete PCI
Case walkthrough:
How to Access the
Subintimal space
Starting an Antegrade dissection plane –
blunt cap:

1 2 3 4
 Tapered cap

?
 Case walkthrough:
The role of Knuckle wire
 Knuckle toolkit

Wire: Fielder XT (R) Wire: Pilot 200

0.8g Polymer Jacket Tapered .009” 4.7g Polymer Jacket

 Technique development Knuckle Boss

The Knuckle
• Helps manage
resistant lesions

• Negiotiate
sidebranches
Knuckle wire technique
Knuckle wire to resolve proximal ambiguity
Resolving proximal cap ambiguity – CTA
Managing the Sub-intimal Space to Facilitate
Knuckle CTO vsPCICrossboss
 Knuckle vs Crossboss

Knuckle wire CrossBoss

Subintimal Space True Lumen
Whole Case Walkthrough:
Managing the Sub–Intimal Space During
Antegrade Dissection Re-entry:
Shearing Tissue Planes

Helps negotiate ambiguity,

tortuosity and resistance,
but exposes sub-intimal
space to arterial pressures

The larger the space the

higher the risk of losing
distal vessel visualization
The problem
Anatomical risk factors for
loss of distal bed filling

High dependence on
ipsilateral collaterals

Small, diseased distal

vessel

Poor collateral filling (CC0

/ 1)
Procedural Risk factors for
loss of distal bed filling

• Large “knuckle”
• Propagation of distal wire
position
• Antegrade (micro-
catheter) guide injection
Procedural Risk factors for loss
of distal bed filling

• Large “knuckle”
• Propagation of distal
wire position
• Antegrade (micro-
catheter) guide injection
Procedural Risk factors for loss
of distal bed filling

• Large “knuckle”
• Propagation of distal
wire position
• Antegrade (micro-
catheter) guide
injection
Procedural Risk factors for loss
of distal bed filling

• Large “knuckle”
• Propagation of distal
wire position
• Antegrade (micro-
catheter) guide
injection
 Options following loss of distal
visualization
• Blind stick
– Low yield for success
• IVUS guided re-entry
– Does not treat sub-intimal problem
• Attempt re-entry more distally
– Risks loss of more distal branches
– Risks further propagation of sub-intimal hematoma
• Discontinue procedure
– Return > 6/52 for repeat attempt
• STRAW technique
 STraW

Sub-intimal hematoma
Distal lumen compression

Aspiration

Decompression &
Re-entry
Rules for working in the Sub-intimal
Space (antegrade)
• No Antegrade injections
• No microcatheter injections
• Control knuckle
– Not too big
– Not too far
• Meticulous control of position during exchange
– Use trap technique
• Use of CB catheter
– Knuckle to redirect
• Control inflow to sub-intimal space
ADR in More
Complex Cases

Blunt/amb prox cap: 1

CTO length > 20mm: 1
No Ca+: 1
No tortuosity: 0
Previous failure: 1
 Challenging
Proximal Cap

• Balloon Anchor
– Side vessel
– Co-axial main vessel
– Anchor Tornus
• Deliberate balloon rupture
• ‘Carlino’
• “Scratch and go” - Enter
subintima proximal to the
CTO cap and go around
• Adjuncts - rotablation
 8F AL-1
Corsair
guide

Side branch anchor

balloon

Knuckle Fielder XT

Confienza P12 passes 1-2mm into CTO Also attempted: Anchor Tornus
segment
Deliberate balloon rupture
Corsair advanced as far as possible
Co-axial main vessel balloon anchor
Swapped for Fielder XT knuckle
Forsythe19 AVI
 <5 mins CrossBoss to
distal
architecture
Knuckle wire to
main RCA
architecture

<10 mins
Stick &
Swap Stingray
Deployed
<5 mins
Forsythe52 AVI
Ostial Occlusions
Carlino manoeuvre to create micro-dissection
Knuckle wire safely into architecture
Switch out to CrossBoss
Deploy Stingray, stick and swap
Complete the Case
Antegrade dissection
Re-entry

Teachable

Safe

Effective

Efficient
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