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Chronic Total Occlusion PCI – Strategies Dr Arun. CTO-DEFINITION 100% luminal diameter obstruction without flow in that segment of 3 or more months duration Presence of TIMI 0 flow within an occluded segment with an estimated occlusion duration of >/= to 3months.

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Chronic Total Occlusion

PCI – Strategies

Dr Arun



100% luminal diameter obstruction without flow in that segment of 3 or more months duration

Presence of TIMI 0 flow within an occluded segment with an estimated occlusion duration of >/= to 3months

A lesion with TIMI 0 flow within the occluded segment

that is judged to be at least 3 months in duration

Eurointerven 2007 :30:43

Heart 2012;98:822-828



Significant clinical problem (JACC intvn 2009;2:489 –97)

Similar risk to non CTO PCI (JACC intvn2009;2:489 –97)

Angina relief (FACTOR TRIAL-2010)

Improved L V function JACC 2006;47:721–5

Improved tolerance of a future ACS JACC intvn2009;2:1128 –34

Potentially better survival with successful PCI

AmHeartJ 2010;160:179-87

Avoidance of CABG AmHeartJ 2010;160:179-87



Aim – To improve symptoms and/or prognosis

Currently reopening of a CTO

Presence of symptoms


Objective evidence of viability/ischaemia in territory of

occluded artery of more than 10% is fully sanctioned by the

current guidelines on myocardial revascularisation



Limited or no late enhancement on Gd MRI is an excellent

predictor of late left ventricular recovery after CTO


EuroIntervention 2012;8:139-145



Healing total occlussion

Fibrin-red, proteoglycan-bluishgreen

Vascular channels- asterisks

Asterisks- vascular channels

Yellow- collagen rich matrix



Histopathological progression – not clearly understood

Belief –once occlusion occurs thrombus formation uptosidebranch

Important components of occlusion

Proximal cap, Calcificationmicrovessels ,loose tissue, distal cap


Often extend to smallside branch & to adventitia

Extravascular microchannels in early phase of occlusion

More mature CTO –intravascular channels increase

Matured CTO - both fewer

Longitudnal continuity – 85% of entire lenghth of CTO


J Am CollCardiolIntv 2011;4:941–51


Continuous loose tissue segments frequently in tapered entry CTO

Majority of CTO autopsy specimen were not totally occluded

Non occluded lesions were not related to the age

Histopathologicalsubintimal space after failed procedure

Sumitsujiet al

JACC intvn sep 2 0 1 1 : 9 4 1 – 5 1


Preprocedure planning

Paramount importance – planning mistakes difficult to circumvent half

way through the procedure

Discourage routine adhoc CTO PCI

Spend time examining diagnostic films & decide on

Approach ,vascular access, guide shape & size

dedicated equipment availability

Occluded & contralateral vessel reviewed in multiple projection

frame by frame to

understand complete anatomy

identify proximal & distal cap

vessel course & sidebranch


details of collateral circulation

Contrast volume defined prior to procedure - 4xGFR(ml)

EURO CTO club;2012 consensus


Role of dual injection

Critical for performing CTO PCI–in all case of contralateral collateral

Allows for optimal visualization of CTO vessel

Crucial for determining lesion length, size & location of distal

target vessel

To asses any bifurcation at distal cap

Assess presence, size & tortuosity of collateral vessel

Best performed

At low magnification ,prolonged imaging exposure

No table panning - allows for optimal delineation of CTO segment

collateral vessel location & course

JACC intrvn2012;5:367-79


First inject donor – then occluded vessel – minimize radiation

Septal collaterals best visualized –RAO cranial OR straight RAO

Epicardial collaterals need tailored view

more often from diagonal ,LCX or PLV

LAO & RAO cranial – Best to image distal lateral wall collaterals

(OM-PLV, diagonal to diagonal/OM connections)

RAO & AP caudal- proximal OM collaterals and those in AV groove

JACC intrvn2012;5:367-79


Repeat procedures – when to stop

Repeat procedures – More common with CTO

failure of a specific recanalization strategy

staging of otherwise progressing procedure

Parameters to consider before repeat procedure

First attempt complete ?

contemporary technique & materials properly employed

reason for failure recognized ?

clear alternative strategy for reattempt ?

General rule- two attempts at a CTO

Know when to stop key issue in CTO PCI

dissection of distal lumen – Better to abandon procedure



UFH – ease of use & available antidote

Avoid bivaluridin &gp 2b 3a inhibitor

Access route

Depend on individual patient situations

Operator preference & experience

Femoral artery - usual and preferred access

in most labs(90% - Europe)

Trans radial PCI for CTO - increased

Korean Circ J 2010;40:209-215

Brilakis et al,2012


Bifemoral approach - characteristic of CTO PCI

Side hole guide catheters >/= 7F - both

antegrade & retrograde

Long femoral sheaths (>/=30cms) - further

support (tortuous arteries)

Back up support & sidehole - essential in

guide selection

IVUS guided PCI - 8 F guide catheter to

accommodate 2 catheters

(IVUS catheter and microcatheter)

Simultaneous double contrast injection is mandatory

Yamane M. Rev EspCardiol. 2012.


Successful CTO PCI require attention to subtle techniques

Guide wire crossing of CTO –most difficult & important

Guidewire selection & manipulation tactics – key issues

Successful guidewire manipulation requires adequate preparation, guide selection & angiographic techniques


Guide catheter selection

First key to success

For effective guide wire manipulation :

coaxial orientation of guide catheter important

stability& back up force

RCA - AL1/0.75 with sideholes

Shepared crook RCA - AL1or2

Prox RCA lesion - JR ( avoid ostial damage)

LCA - Extraback up (XB,EBU,BL)

LCX (short leftmain) - AL1 or2 (better support & co-axial)

Guide catheter stability insufficient or unable to achieve

May use Anchor technique for guide catheter stabilization

Korean Circ J 2010;40:209-215


AL from different companies

Anchoring technique

for guide stabilization

OTW baloon inserted in a small sidebranch inflated at low pressure (2mm @ 8atm here)



Guide wires

Crossing the lesion with GW – very important step in CTO PCI

Most common reason for failed CTO PCI- failure of GW to cross

Floppy wire- initial choice

Exchange to a stiffer dedicated guide wire

Polymer coated wires – poor tactile feedback, lack of resistance

more chance of subintimal passage

Majority favour – step up approach – moderately increased stiffness(miracle-3) – switch to greater stiffness &penetration ability, taperd (conquest pro wires)

Some believe –use of stiffer wires initially to cross hard occlusion cap

Rationale: risk of initial dissection minimized,

procedure shortened & simplified with this approach

Kcj 2010


Four wire strategy

Hydrophillic &/or polymerjacketAntegrademicrochannel/

0.014 inch,low gram force with soft tissue probing

tapered tip knuckle technique

Eg : Fielder XT wire (Asahi Intecc) tip-0.009

Runthroughtaper wire (Terumo – 0.008

Nontapered ,polymer jacket collatrel channel crossing

Hydrophillic,0.014 inch GW in retrograde procedures

Eg: Fielder FC wire(Asahi Intecc)

Pilot 50 wire (Abbott Vascular)

JACC intrvn2012;5:367-79


Moderately high gram force(4-6) complex lesion crossing

Polymer jacket,nontapered long lesion,knuckle technique

0.014 inch GW Dissection /rentry

tortuous lesion with ambigous


Eg: Pilot-200 GW(Abbott Vascular)

High gram force ,0.014GW Penetration techniques

tapered,0.009 Cap puncture

Nonjacketed tip Complex lesion crossing

Lumen reentry techniques

Eg: Confianza Pro 12 wire (Asahi Intecc)

JACC intrvn2012;5:367-79


Guide wire selection & Microcatheter based on PCI strategy


a) Tapered (0.009 in) or not

b) Polymer jacket or not

c) Stiffness

d) Trackability

Initial microchannel tracking - soft tapered polymer jacket wire

IVUS guided reentry from subintimal space to true lumen

Tapered High gram stiff wire

Soft polymer jacket wire + microcatheter has improved chance of antegrade recanalization in first attempt



Low profile,trackable OTW microcath - indispensable tool for CTO PCI

Allow ease of wire exchange ,floppy for dedicated stiffer wire

Facilitates transmission of torque to tip & improve feedback

Allows primary & secondary curve adjustment

Modulates tip stiffness of guide wire

Dedicated microcatheters – better tip flexibility > OTW balloons

Useful for CTO immediately distal to a bend

Larger inner lumen – reduces friction during wire manipulation

Disadvantage : rarely able to cross occlusion

to be exchanged with OTW baloons


Tips for use

For wire exchange – inject saline to lumen- avoids introducing air

Trapping technique





Rotate anticlockwise to advance

Clockwise to remove

Screw pitch


Tornus 88Flex - 1.7mm

Require exchange length wire for removal



Tapered soft tip

Negotiate tortuous channels

Platinum marker

Distal 60 cm- hydrophilic coating

Corsair Features

Tungsten braiding +10 elliptical stainless steel braids


Excellent pushability and flexibility due to unique construction

Enables contrast injection and wire exchange

Superb manoeuvrability due to excellent hydrophilic coating

Kink resistant soft radiopaque tapered tip

135cm (antegrade) or 150cm (retrograde) lengths available





Soft tapered polymer jacket wire

Parallel wire technique

Middle weight spring coil wire

Bilateral retrograde approach

High gram tapered wire

IVUS guided approach

Yamane M Rev EspCardiol. 2012.


Attempted in this order chance of successful recanalization - 90%

Clinical background & situation dictates - onetime or a staged procedure

2nd or 3rd attempt in case if unsuccessful procedure

Yamane M Rev EspCardiol. 2012


Guide wire Tip shaping

Wire tip shaped as short as possible <45º

Second milder curve - improve maneuverability of wire

Exception - a sharp (>60º) angle with 1 to 2 mm bend based on lumen size, to navigate the wire from subintimal space back to true lumen( Parallel wire technique or IVUS guided wiring)

Confianza Pro or Pilot 200 - best suited to this purpose

How short tip can be bent – depends on length of soldering of spring coil at tip

Usually -1mm, fielder XT -<1mm

Korean CircJ 2010;40:209-215



Shaping the wire

1ºbend of 30-45º

1-2mm from tip

Find softest part



Work as a navigator

to orient tip


Tip curve should be just larger than lumen diameter

CTO, the lumen diameter =0 mm

For CTO lesion - Guidewire-tip curve should be very small

Larger curve may hurt the vessel wall during direction control

Hermiller ,SCAI Fellows Course 2009


Guide wire handling

Different methods

Sliding AT proximal cap

Drilling inside CTO

Penetration Distal cap

Short, focal, straight noncalcified lesion – any method

Long tortuous calcified occlusion – wiring tailored to lesion


Hard fibrocalcific plaque and tortuosity in CTO- major obstacle

Combination of penetration and sliding over a microcatheter

watching the wire tip in relation to lumen in at least 2

orthogonal views

Yamane M Rev EspCardiol. 2012



Relatively recent occlusion with predominance of microchannels

Extremly low friction wires for picking microchannels used

Simultaneous rotation & probing of lesion

High chance of entering to subintimal space ( tactile response - nil )

Recent total, subtotal occlusion ,ISR attempted with this strategy

Long duration – Microchannels replaced by fibrotic tissue

Indian Heart J. 2009; 61:275-280


BEWARE bridging collaterals masquerading as microchannel

Polymer sleeved wires NOT forced against resistance, small tip bend, probing with mild rotation

Soft wires with polymer sleeve – Fielder series/ Whisper/ PT II


Drilling Strategy

If discrete entry point present


short curve(2mm) @45-60º to distal tip

sometimes a secondary curve given proximally

wire advanced with rapid rotational tip and gentle probing

start with MOD stiffness – progressive increase in stifness

Entry to false lumen judged by tactile feel on pulling stiff wire

Reserved for the most skilled and experienced operator

Ineffective with Blunt entry ,heavily calcific & resistant lesions

Indian Heart J. 2009; 61:275-280



Useful for blunt ,heavily calcific or resistant lesions


Pushing stiff wire slowly& gradually – minimum rotation to target direction

Tapered tip wires

Softer tip intially progressively stiffer wires

Route determined – various angio or CT findings not by tactile feel

Not for CTO with tortuous angulated or bridging collaterals because of higher chance of perforation

Drilling & penetration – guide support & tipload important

Tip load - success - chance of perforation


Penetration power = tipload/tiparea

May use to redirect in conjunction with parallel wire technique


1st wire in false channel

left in situ

2nd stiffer wire advanced parallel to first wire in same path

redirected to enter distal true lumen

Important prerequisite – distal vessel visualization

Main purpose : - redirecting a wire inside body of a cto & puncturing distal fibrous cap

main pitfall is wire twisting each other

Support catheter use, appropriate wire selection& handling –essential to avoid wire twisting

Korean Circ J 2010;40:209-215


Visualization of 1st GW & its relative position to 2nd GW using orthogonal view is essential for success of technique

Adopt the technique before a large subintimal dissection

Chance of successful recanalization by 2nd wire decreases proportionally to the extent of subintimal dissection induced

by the first guidewire

2nd wire –stiffer with superior torquability

Eg:Miracle12 or Conquest Pro


Check in multiple angiographic views


a)Decreased fluro time

b) Reduced contrast


See-saw wiring technique

Modification of parallel wire technique

Uses 2 microcatheters or OTW baloons

When first wire fails , 2nd wire with microcatheter or OTW baloon is inserted

Risk – false lumen may enlarge – procedure failure

Japanese operators demonstrated ability to improve wire crossing over time with this technique(Nakamura& Bae 2008)


IVUS Navigated Wiring

IVUS – Depict cross sectional view of coronary tree

IVUS focus on plaque distribution, calcification, reference vessel size & side branch anatomy

Applicability of IVUS in CTO PCI

1)Side branch method to navigate CTO wire into true lumen from proximal cap

2)Subintimalrentry from the proximal true lumen

IVUS guided subintimalrentry – Last resort for getting a subintimal wire into distal true lumen

Applicable even after losing site of distal vascular bed on angio


1.5-2mm baloon dilatation in presumed subintimal space

IVUS is advanced into the space monitored to orient 2nd wire to true lumen

Key points

Ability to translate crosssectional image into 3D needed

2nd stiff tapered wire over microcatheter - 8f guide mandatory

Rentry point should be closer to proximal cap

Contrast injection should be withheld esp after small ballon dilatation


Importance of wire crossing from true lumen to true lumen

If Subintimal wire crosses without many side branch compromise

Subintimal stenting practical

Larger distal vascular bed – higher chance of TIMI-3 flow

CTO PCI should be planned to minimize subintimal wiring

Subintimal wiring & stenting – unavoidable in some

Eg: severe fibrocalcific occlusion over a negatively remodelled segment


Dissection reentry techniques

STAR Technique - Subintimal tracking and rentry technique

Used when attempts to recanalize true lumen failed

0.014 hydrophillic wire with J configration used(whisper,pilot)

Hydrophillic wire pushed through subintimal dissection plane

When pushed distal to occlusion J tip directed to truelumen

In an attempt to reenter

Successful in those with previous attempt failed

High chance of perforation

Catheter CardiovascInterv 2005;64:407–411


Knuckle wire technique

Similar to wire loop technique used in long SFA occlusion

Polymer jacket wire (fielder XT or pilot-200)manipulated

to create wire loop – advanced subintimally-across CTO –

OTW system advanced to this area- rentry to true lumen with a stiffer wire or pilot 200


Cross Boss catheter

Metal OTW microcatheter with rounded tip to prevent vessel exit

Device rotated rapidly in either direction using fast spin

Can advance through the CTO without a wire in the lead

Subintimal position- true lumen reentry performed

Smaller subadventitial space – less likely to accumulate blood


Sting ray balloon & guidewire system

1mm flat balloon with 3 exit ports connected to the same lumen

Distal exit port – for balloon positioning

Other 2 180º opposed to each other

Uses guidewire with extreme tapered tip (0.0025) for rentry

Distal true lumen entry confirmed by contralateral injection


Initially used after a failed antegrade approach

Now used as initial strategy in challenging cases

1) Ostial occlusion 4) Large side branch at proximal cap

2) Long occlusion (>30mm) 5) Severe tortuosity or calcification

3) Without stump 6) Visible continuous collatrels

Dual femoral arterial access preffered

Long sheaths for additional passive support

Anticoagulation – heparin ,ACT at least every 30min - >350 sec

Use of short guide allow long reach


Collateral selection

Preference - Bypass graft > septal > epicardial

Selective injection of collateral

Surfing technique for crossing invisible septal collateral

Wiring collateral – achieved with OTW system or dedicated


Entering septal collaterals large bend or 2 small bend in a work

horse wire

Contrast injection to assess best connection

Before injection – aspirate to remove air in microcatheter

Dripping saline over hub during insertion& removal of guidewire


Hydrophillic polymer jacket wire with <1mm 30-45º tip used

to cross recipient artey

Fielder FC,Pilot-50,Whisper, Choicept,Runthrough

Wiring done in diastole

Wire should move freely - difficulty to advance – perforation?

PVC or whipping of wire - RV or LV entry (rarely pericardium)

Of no consequence if recognized before advancing OTW system

Collateral dilatation using 1.5 mm balloon @ 1-2 atm or Corsair

Epicardial collaterals

size most important factor in wiring success

should never be dialated


Antegrade crossing

Simplest form of retrograde technique

Retrograde wire advanced to distal cap

Acts as a marker of distal true lumen

Serves as a target for antegrade wire

Saito, Catheterization and Cardiovascular Interventions 71:8–19 ,2008


Kissing wire

Manipulation of both antegrade and retrograde wires in CTO until they meet

Antegrade wire follow channel made by retrograde wire in true lumen of distal vessel


Retrograde true lumen puncture

Most pure form of retrograde technique(only in 40% retro tech)

Hydrophillic wire advanced to the lesion

Advancment of microcatheter or OTW baloon – additional support

CTO crossed retrogradely using hydrophillic wire or stiffer wire

Manuevers to enhace chance of crossing

Inflating retrograde baloon - coaxial anchor

Stiffer tapered tip or hydrophillic wires

IVUS facilitation of retrograde wire to proximal true lumen



Controlled antegrade & retrograde subintimal tracking

Basic concept –create subintimal dissection with limited extension only at the site of a CTO

Antegrade wire advanced into CTO then to subintimal space.

Retrograde wire through collatrel with microcatheter to distal end of CTO - into the CTO- then to subintimalspace

Baloon inflation inside CTO using small balloon over the retrograde wire to subintima

Balloon inflated inside CTO

To keep inflated space open deflated baloon left in subintimal space

SurmelyJf et alnJInvasive Cardiol 2006;18:334–338


Two subintimal dissection provide reentry space for antegrade wiring

Antegrade wire advanced along deflated retrograde balloon into the distal true lumen

Dilatation and stent implantation after successful recanalization

Limited subintimal tracking (dissection) only in CTO segment

Avoids difficulty of reentering distal true lumen


Use closest sized baloon inside CTO to create sufficient wire reentry space

Access to distal CTO mainly via septalcollatrels,

by polymer jacket wire over microcatheter or otwbaloon

Septal channel dilatation at 1.25mm baloon at low pressure

Major limitations

Limited access of collatrel channels to target CTO

Empiric estimation of retrograde baloon size

Overall unpredictable procedure time


Reverse CART technique

Engage a guidewireretrogradely in the distal cap of the CTO

Another wire anterogradely in the proximal cap of the CTO

Retrograde wire advanced in subintimal space into CTO lesion

Subintimalchannel is enlarged by anterograde balloon

Plaque dissection and modification of the lesion

Retrograde wire advanced to cross the dissection

Link up with the anterograde wire in proximal true lumen

Wire externalized (Exchange length)

Anterograde PCI done



Best suited for long segment of occlusion

Retrograde wire usually a polymer jacket wire manipulated to form a loop at wire tip advanced in subintimal space across CTO

Eg: Fielder XT or Pilot-200

Rounded wire loop advanced in subintimal space across CTO without causing perforation

OTW system advanced to this area followed by attempt to reenter

true lumen using a stiffwire with short bend or hydrophillic wire

Eg: Confianza Pro 12 or Pilot 200


Treating lesion after crossing

CTO crossed by antegrade wiring (kissing wire, just marker,CART

Antegrade CTO PCI can be done

Retrograde balloon can trap antegrade wire to facilitate procedure

Retrograde wire crosses to true lumen

Options : Antegrade wiring

Retrograde wire externalization

Retrograde stent delivery

DES is preferred in CTO PCI


Antegrade wiring

Retrograde baloon angioplasty

Antegrade wire crosssing - stenting

Double anchoring technique for support

Facilitated by

Antegrade micro catheter probing technique

Bridge or Rendezvous method

Reverse wire trapping

Viper advance wire preffered for retrograde wire externalisation

Retrograde stent delivery – risk of stent entrapment & dislodgment



Thrombosis and dissection of donor artery

Collateral perforation & occlusion

treated with coil embolization

injection of autologus subcutaneous fat tissue/thrombus

emergency CABG

Entrapment of pci equipment in septal collaterals

Radiation skin injury/CIN/

Subintimal stenting – late coronary aneurysm & stent fractures


Cross-it 100XT


Abbot vascular

Tip load-1.7gm

Tapered tip coil design (0.014” to 0.010” at distal 3 cm)

Hydrophilic coating over distal 30 cm

PTFE coating over proximal portion

Stainless steel core


Abbot vascular


Tip load: 1.5gRadiopaque length: 3 cmOutside diameter: 0.014"Tip Outside diameter: 0.014" Coating: HydrophilicTip style: Core to tipPolymer cover: Full Polymer CoverCore Material: DURASTEEL Stainless Steel

Also available


200- 4.1g



  • Tip load: 0.8gRadiopaque length: 3 cmOutside diameter: 0.014"Tip Outside diameter: 0.014"Coating: HydrophilicTip style: Core to tipPolymer cover: Full Polymer CoverCore Material: DURASTEEL Stainless Steel

RCA with down ward take off- JR or AL

Male asian patients - Brite tip-(deeper 2º curve)

Female asian patients - Launcher SAL-1

ProxLAD Judkins short tip

LAD & circumflex- EBU or Voda