Fig. 3.1
An example of one antegrade and retrograde technique for crossing a CTO. (a) The antegrade approach requires defined proximal cap anatomy ideally with a tapered stump or defined entry point. In parallel wiring, a first wire is passed into the subintimal space and left in position to seal that tract and act as a marker, while avoiding the cap of the distal true lumen. A second penetrating wire is then introduced via a microcatheter to attempt redirection into the true lumen. (b) The retrograde approach is usually reserved as a second line strategy for failed intimal antegrade crossing but suggested as a first line where the proximal stump is ambiguous. In the reverse controlled anterograde and retrograde tracking and dissection (reverse CART) technique a balloon is inflated over the antegrade wire within the subintimal (subluminal) space that is connected proximally to the true lumen. The retrograde wire is advanced toward the newly created space
Increasingly sophisticated guidewires have been developed for arterial tissue penetration and easier steering through lesions (Table 3.1). If an occlusion cannot be crossed, for example because of heavy calcification, wires can be used to enter the wall of the coronary artery. Using wires with slippery coatings attempts can then be made to pass the occluded segment via the subintimal arterial plane, and then to re-enter the lumen distally. Special devices such as the CrossBoss TM and Stingray Re-Entry System TM (Boston Scientific, Natick, MA, USA) can help guide a sharp wire back through the vessel wall into the lumen (Fig. 3.2a, b). This technique is called anterograde dissection re-entry (ADR; Case Study 1).
Table 3.1
An overview of currently available wires used in CTO
Wire | Manufacturer | Design/lengths | Coating | Tip load (g) | Penetration force kg/in.2 |
|---|---|---|---|---|---|
Fielder FC | Asahi | Non-tapered tip. 0.014 in., 180 and 300 cm lengths. | Hydrophilic, polymer jacket | 0.8 | N/A |
Fielder XT | Asahi | Tapered tip 0.009 in. Shaft 0.014 in., 180 and 300 cm lengths | Hydrophilic, polymer jacket | 0.8 | N/A |
Fielder XT – A (A for antegrade) | Asahi | Tapered tip 0.009 in. Shaft 0.014 in., 180 and 300 cm lengths | Hydrophilic, polymer jacket | 1.0 | N/A |
Fielder XT – R (R for retrograde collateral cross) | Asahi | Tapered tip 0.009 in. Shaft 0.014 in., 180 and 300 cm lengths | Hydrophilic, polymer jacket | 0.6 | N/A |
Pilot 50 | Abbott | Non-tapered tip. 0.014 in., 190 and 300 cm lengths | Hydrophilic, polymer jacket | 1.5 | N/A |
Sion For retrograde collateral cross | Asahi | Non-Tapered tip. 0.014 in., 180 and 300 cm lengths | Hydrophilic, non-jacketed over spring coil and tip. | 0.7 | N/A |
Sion blue Workhorse wire for procedure completion | Asahi | Non-Tapered tip. 0.014 in., 180 and 300 cm lengths | Hydrophilic, non-jacketed over spring coil. Hydrophobic tip. | 0.5 | N/A |
Gaia first | Asahi | Tapered tip 0.010 in. Shaft 0.014 in., 190 cm | Hydrophilic, non-jacketed. Tip hydrophilic | 1.5 | Penetration efficiency rather than power. On par with miracle 6 |
Gaia second | Asahi | Tapered tip 0.011 in. Shaft 0.014 in., 190 cm | Hydrophilic, non-jacketed. Tip hydrophilic | 3.5 | Penetration efficiency rather than power. On par with miracle 12 |
Gaia third | Asahi | Tapered tip 0.011 in. Shaft 0.014 in., 190 cm | Hydrophilic, non-jacketed. Tip hydrophilic | 4.5 | Penetration efficiency rather than power. On par with Conquest Pro 12 |
Miracle 3/MIRACLEbros 3 | Asahi | Non-tapered tip. 0.014 in., 180 cm length | Hydrophobic (silicone) | 3.0 | 20 |
Miracle 4.5/MIRACLEbros 4.5 | Asahi | Non-tapered tip. 0.014 in., 180 cm length | Hydrophobic (silicone) | 4.5 | 30 |
Miracle 6/MIRACLEbros 6 | Asahi | Non-tapered tip. 0.014 in., 180 cm length | Hydrophobic (silicone) | 6.0 | 39 |
Miracle 12/MIRACLEbros 12 | Asahi | Non-tapered tip. 0.014 in., 180 cm length | Hydrophobic (silicone) | 12.0 | 78 |
Ultimate Bros 3 | Asahi | Non-tapered tip. 0.014 in., 180 and 300 cm lengths | Hydrophilic, non-jacketed | 3 | 20 |
Pilot 150 | Abbott | Non-tapered tip. 0.014 in., 190 and 300 cm length | Hydrophilic, polymer jacketed | 2.7 | N/A |
Pilot 200 | Abbott | Non-tapered tip. 0.014 in., 190 and 300 cm length | Hydrophilic, polymer jacketed | 4.1 | N/A |
Conquest/Confianza | Asahi | Tapered tip 0.009 in. Shaft 0.014 in. 180 cm length. Spring coil length 20 cm | Hydrophobic (silicone) | 9.0 | 142 |
Conquest Pro/Confianza Pro | Asahi | Tapered tip 0.009 in. Shaft 0.014 in., 180 cm length. Spring coil length 20 cm | Hydrophilic non-jacketed over spring coil. Hydrophobic tip and shaft | 9.0 | 142 |
Conquest Pro 12/Confianza Pro 12 | Asahi | Tapered tip 0.009 in. Shaft 0.014 in., 180 cm length. Spring coil length 20 cm | Hydrophilic non-jacketed over spring coil. Hydrophobic tip and shaft | 12.0 | 189 |
Conquest Pro 8–20/Confianza Pro 8–20 | Asahi | Tapered tip 0.009 in. Shaft 0.014 in., 180 cm length. Spring coil length 17 cm | Hydrophilic non-jacketed over spring coil. Hydrophobic tip and shaft | 20.0 | 315 |
High torque CROSS IT 100 XT | Abbott | Tapered tip 0.010 in. Shaft 0.014 in. 190 and 300 cm length. | Hydrophilic including tip, non-jacketed | 1.7 | 22 |
High torque CROSS IT 200 XT | Abbott | Tapered tip 0.010 in. Shaft 0.014 in. 190 and 300 cm length. | Hydrophilic including tip, non-jacketed | 4.7 | 60 |
High torque CROSS IT 300 XT | Abbott | Tapered tip 0.010 in. Shaft 0.014 in. 190 and 300 cm length. | Hydrophilic including tip, non-jacketed | 6.2 | 79 |
High torque CROSS IT 400 XT | Abbott | Tapered tip 0.010 in. Shaft 0.014 in. 190 and 300 cm length. | Hydrophilic including tip, non-jacketed | 8.7 | 110 |
High torque Progress 40 | Abbott | Non-Tapered tip 0.014 in. 190 and 300 cm length. | Hydrophilic, non-jacketed. | 4.8 | 30 |
High torque Progress 80 | Abbott | Non-Tapered tip 0.014 in. 190 and 300 cm length. | Hydrophilic, non-jacketed. | 9.7 | 63 |
High torque Progress 120 | Abbott | Non-Tapered tip 0.014 in. 190 and 300 cm length. | Hydrophilic, non-jacketed. | 13.9 | 90 |
High torque Progress 140T | Abbott | Tapered tip 0.0105 in. Shaft 0.014 in. 190 and 300 cm length. | Hydrophilic, non-jacketed. | 12.5 | 144 |
High torque Progress 200T | Abbott | Tapered tip 0.009 in. Shaft 0.014 in. 190 and 300 cm length. | Hydrophilic, non-jacketed. | 13.3 | 209 |
Galeo hydro S | BIOTRONIK | Non-tapered tip. 0.014 in. 175 cm length. | Hydrophilic 12 cm including tip. Hydrophobic shaft. Non-jacketed
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