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The Essential Equipment for CTO Interventions
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One of the most frequently asked questions about chronic total occlusion interventions, especially from institutions starting a CTO program, is: “What equipment do I really need?”
Emmanouil S.
Brilakis
Although most of us would like to have everything possible in our lab, the reality is that due to cost and space limitations, we need to prioritize. Here are some criteria to use when deciding the “must haves” for CTO interventions:
• Equipment serves a unique function;
• The operator is familiar with the equipment, understands its strengths and limitations and is willing to use it (otherwise it will expire on the shelf, although the latter is desired for complication management equipment, such as covered stents and coils).
The table shows a “must have” and “nice to have” checklist for CTO PCI equipment, which divides equipment into the following 10 categories.
1. Sheaths
We routinely use 45-cm long sheaths for better guide catheter support and torquability. Although this is not absolutely necessary, CTO PCI can be challenging and it is optimal to attempt crossing under the best possible conditions.
2. Guide Catheters
We routinely use a bifemoral approach with bilateral 8F guides for better visualization and support and for easy conversion to the retrograde approach, if needed. Short guides facilitate performance of the retrograde approach. In our laboratory, we tried 80-cm long guides, but they were too short in many patients, whereas 90-cm long guides seemed to work well for nearly all patients. The “must have” guide shapes are XB or EBU for the left coronary artery, and AL or JR4 for the right coronary artery.
3. Microcatheters
It is standard practice in our laboratory to always attempt CTO crossing with a wire advanced through a microcatheter, due to superior wire support and penetration and to allow easy wire exchanges. FineCross (Terumo) is very flexible and is our first choice for antegrade crossing, whereas Corsair (Asahi Intecc) is a “must have” for the retrograde approach, especially through septal collaterals, as it also dilates the collateral. Although some operators prefer to use over-the-wire balloons instead of microcatheters, balloons are stiffer and have a marker in the mid shaft (for 1.20-mm, 1.25-mm and 1.5-mm balloons), therefore not allowing accurate understanding of the catheter tip location within the target vessel and lesion. The Venture catheter (Vascular Solutions) has a deflectable tip and can be extremely helpful across angulated lesions (the classic example is ostial circumflex CTOs).
4. Guidewires
This is the area with the largest number of options, as well as personal preferences. However, great progress has been made lately in limiting the options down to five “must have” wires (in no particular order):
1. Fielder XT (Asahi Intecc), which is a soft, polymer-jacketed, tapered wire for initial antegrade crossing;
2. Confianza Pro 12 (Asahi Intecc) for subsequent attempts, if the course of the vessel is well understood;
3. Pilot 200 (Abbott Vascular), when the course of the target lesion and vessel is uncertain;
4. Fielder FC (polymer-jacketed soft wire, Asahi Intecc) or Sion (hydrophilic, highly torquable soft guidewire with excellent shape retention, Asahi Intecc) for wiring collaterals during retrograde crossing;
5. Viper (335-cm long, CSI) or R350 (350-cm long, Vascular Solutions) wire for externalization.
For operators performing transradial CTO PCI, availability of 300-cm long guidewires and guidewire extensions is important, as the “trapping” technique for exchanging over-the-wire to rapid exchange equipment may not always be feasible through a 6F guide catheter.
5. Dissection/Re-Entry Equipment
Although dissection/re-entry can be accomplished using wires, the CrossBoss catheter and the Stingray balloon and guidewire (BridgePoint Medical/Boston Scientific) are preferred, as they are currently the only FDA-approved devices for coronary CTO interventions and have been shown to improve success rates in cases that could not be crossed using standard crossing techniques.
6. Snares
Snares are often needed for inserting the retrograde guidewire into the antegrade guide catheter. The three-loop (tulip) snares, such as the EN Snare (Merit Medical) and the Atrieve (Angiotech) are more effective in capturing the guidewire compared with the single-loop snares, such as the Amplatz GooseNeck snare (ev3).
7. “Uncrossable - Undilatable” Lesion Equipment
The second most common reason for CTO PCI failure is failure to dilate the lesion after wire crossing. This can be facilitated by increasing guide catheter support (eg, using the GuideLiner catheter [Vascular Solutions] and various anchor balloon techniques) or by modifying the lesion by using the Tornus catheter (Asahi Intecc) or various other modalities, such as rotational atherectomy or laser.
8. IVUS
Intravascular imaging can facilitate identifying the lesion proximal cap and confirming retrograde guidewire position into the proximal true lumen before externalization. A short-tip solid state IVUS catheter was recently introduced in the market (Eagle Eye Short Tip, Volcano) and is preferred for imaging in CTO PCI compared with rotational IVUS systems.
9. Complication Management
Although this equipment is rarely needed, it must be available not only for CTO PCI, but also for any other PCI. There is currently only one covered stent (Jostent, Abbott Vascular) available in the United States for use in large vessel perforations. Coils should also be available for use in case of distal branch or collateral vessel perforation.
10. Radiation Protection
Given the often long duration of CTO PCI and the high fluoroscopy time, it is ideal to minimize radiation exposure for both patient and operator. There are several radiation protection pads that decrease scatter radiation from the patient, such as the RadPad (Worldwide Innovations & Technologies).
Final Points
Clearly, there is no “universal” checklist and there is a great component of personal preference, experience and availability in constructing a CTO checklist for each cath lab and operator, but the Table could serve as a starting point. Having the right tool for the right job can significantly simplify the procedure and boost success rates in CTO PCI.
Acknowledgement: The author would like to acknowledge the invaluable comments of Khaldoon Alaswad, MD; Christopher E. Buller, MD; M. Nicholas Burke, MD; Tony DeMartini, MD; Santiago Garcia, MD; J. Aaron Grantham, MD; David E. Kandzari, MD; Dimitri Karmpaliotis, MD; Nicholas Lembo, MD; William L. Lombardi, MD; Ashish Pershad, MD; Stéphane Rinfret, MD, SM; Kendrick A. Shunk, MD, PhD; Craig A. Thompson, MD, MMSc; and Michael Wyman, MD, in creating the CTO equipment checklist.
Disclosure: Brilakis has received speaker honoraria from BridgePoint Medical/Boston Scientific, St. Jude Medical and Terumo; research support from Guerbet; and his spouse is an employee of Medtronic.