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Kambis Mashayekhi
University Heartcenter Bad Krozingen
Euro CTO Club 2017: Friday 13h40
Dedicated CTO kit: microcatheters,
balloons, adjunctive devices
2
Microcatheters for antegrade CTO approach
Finecross 130/150cm
Corsair Pro 135/150cm
M-Cath 135cm
Turnpike Spiral 135/150cm
Microcatheters for antegrade CTO approach
Less Guiding Back up
Ostial or very proximal lesions,
planned ADR
Good Guiding Back up
Not very calcified CTO lesions
Finecross
M-Cath
Corsair
Turnpike Spiral
Rotatable MCPushable MC
Turnpike Spiral - active support
Turnpike Spiral - active support
Microcatheters for septal crossing
Corsair 150cm
Turnpike 150cm
Microcatheters for epicardial crossing
Finecross 150cm
Microcatheters for retrograde CTO approach
Septal Crossing Epicardial Crossing
Rotatable MC Low profile MC
Corsair
Turnpike
>1,5mm < 1,5mm
Finecross
Turnpike LP
Caravel
Mirco 14
Septal crossing with channel dilatator
Thanks to Nicolas Boudou for the great organization and invitation of the JIF CTO in Toulouse 2016
Corsair Pro: push and rotation force
Over-rotation of MC in calcified lesion:
Wire and MC entrapment: Corsair-TIP with Confianza 12g
Complications in collaterals – Over-rotating the MC
Do not force an
over-rotation of the
MC in tortuosity
www.youtube.com: Case 64: Manual of CTO Interventions, 2nd edition
1) Do not use a MC which you
have to push in tiny
collaterals and severe
angulations
2) A rotatable MC may be safer
(Turnpike LP, Corsair)
Complications in collaterals – Pushing MC in
tortuosity
Epicardial Crossing
Tip Configurations
SuperCross Angled Tips
– 130cm & 150cm lengths with 45°, 90° & 120° angles
– XT = extended tip lengthened from 0.65mm to 1.75mm to achieve
more secure cannulation – 130cm & 150cm lengths
Angled Tip - RCX-CTO 09/17
Angled Tip - RCX-CTO 09/17
0,48 (mm)
2.3F
Round shaft
0.97 (mm) crossing
profileOval shaft
Minor axis
2.3F (0.75 (mm)) =
Crossing profile
Major axis 3.3F (1.1 (mm))
Duallumen Microcatheters
Round shaft
1.2 (mm) crossing
profile
© IMDS 2017
6.5 mm
3.3F
Reverse wire technique
1. 2. 3.
5. 6.
Bifurcation CTO wiring
Dual lumen applications
Wiring acute angulated
bifurcations
Parallel wiring technique
4.
Trapping Devices
© IMDS
Shaft stopper Trapper
Shaft stopper TrapIt
Trapping Balloon compatibility chart
© IMDS
Product TrapIt
Guiding Catheter compatibility
Single Lumen Micro catheters
NHancer Pro X; Corsair, FineCross,
Caravelle, Turnpike
6F
Dual Lumen Micro catheters
NHancer Rx; FineDuo; Crusade
6F
Dual Lumen Micro catheters
TwinPass Torque
7F
Stingray LP CTO Re-Entry System 6F
Usefulness of the Shaft Stopper
Usefulness of the Shaft Stopper
Low Profil Balloons
Design
Balloon
0.6 x 5 (mm)
30 ATM rated
Shaft
OD ≤ 1.5F
High push shaft
Best in class shaft profile
5. Scoring design
Short Rx section
Guidewire used as scoring
element
Tip
Low profile
High penetration
95 cm and 105 cm exit markers
Calcified RCX 13.09.2017
After Scoring with Blimp 30 ATM, Finecross, Rotawire, 1,5mburr
Calcified RCX 13.09.2017
Hornet 14g, Finecross couldn’t pass, Scoring with Blimp 30 ATM
Calcified RCX 13.09.2017
Fibrotic tissue: Laser Calcification: Rotablation
Uncrossable and calcified lesion:
Ultra-high pressure balloon: OPN NC
(SIS Medical)
2 balloon layers
Manometer for
high-pressure inflation
2,45 F
60%
50%
25%
36%
15% 14%
0
10
20
30
40
50
60
70
Max. pressure pre Max. pressure post
35 - 40 atm
41 - 45 atm
46 - 50 atm
Maximum pressures for pre- and post-dilatation
10/2010 – 10/2015 n=176 patients n=238 OPN NC balloons
[%]
Data collection by Achim Büttner – Heartcenter Bad Krozingen
Rotablator assisted revers CART
NC-Balloon at 24 ATM
Rotablator assisted revers CART
1,5mm burr
NC Balloon 26 atm SIS Medical 45 atm
Ultra high pressure balloon
SIS Medical 50 atm SIS Medical 55 atm
Ultra high pressure balloon
Final result
NovaCross MC
Walsh S et al., Efficacy and Safety of Novel NovaCross Microcatheter for
Chronic Total Occlusions: First-in-Human Study, J Invasive Cardiol, 2016 Mar.
CenterCross and MultiCross
Jalal S et al, Novel CenterCross and MultiCross devices for
the treatment of infrainguinal chronictotal occlusions: initial single-
centre experience. EuroIntervention. 2016 Jan
Snares
EnSnare
Merit Medical
One Snare (2mm-
35mm)
Merit Medical
150 cm
6F compatible
Vascular
Solutions
Snaring in ostial RCA – CTO (2x6F unlar/radial)
Snaring: “KAM-Snare”
Wire Externalization Techniques for Retrograde Percutaneous Coronary Interventions of Chronic Total Occlusions, K.
Mashayekhi et al. 2017, accepted in EuroIntervention
Snaring: “KAM-Snare”
Wire Externalization Techniques for Retrograde Percutaneous Coronary Interventions of Chronic Total Occlusions, K.
Mashayekhi et al. 2017; accepted in EuroIntervention
Avoid blood loss !!
OKAY II
• Microcatheters for antegrade approach and septal or epicardial
crossing
• Duallumen catheters
• Low profil balloons
• Rotablator
• Ultra high pressure balloons
• Snares
• Special Y-connectors to avoid blood lost
CTO toolkit
Thank you for
your attention!
Thank you!
CTO Wiring Back up force Calcification
and
tortuosity
Subintimal
tracking
Finecross 1,8F Very good
feedback on the
wire tip, due to
low resistance in
the MC
Low active back
up, good push
Very flexible
shaft, low
profile,
Crossing success
depending on
guiding back up
force
Requires almost
very good
guiding back up
Corsair 2,6F Over-rotation of
the wire and MC
may cause wire
and device
entrapment
Very good active
back up
Attention! Do
not over-rotate
Very good
performance in
subintimal;
Power knuckle
may cause tip
prolaps
Turnpike Spiral 2,9F Over-rotation
may cause
device
entrapment
Best active back
up
Excellent in
fibrotic tissues,
like In-Stent-
Occlusion
Excellent back
up in subintimal
space
Antegrade Microcatheter
The is a CTO Scoring Balloon intended to create Initial Opening in heavy calcified/
fibrotic occlusions where the primary crossing is an issue.
Jalal S et al, Novel CenterCross and MultiCross devices for
the treatment of infrainguinal chronictotal occlusions: initial single-
centre experience. EuroIntervention. 2016 Jan
NovaCross
NovaCross
© IMDS
Trapping mechanism comparison
Unique patented shaft bend
mechanism
Telescopic shaft stop
mechanism
Two product codes guiding
catheter length specific
One product code not guiding
catheter length specific
No trapping mechanism setup
required
Trapping mechanism
(telescopic) need to be
adjusted to guiding catheter
length
Free insertion and retraction
of devices into guiding
catheter
Restricted inserion and
retraction of devices into
guiding catheter
© IMDS
Radiopaque Shaft profile ≤2F Hemostasis valve Hub
tip hard stop
2.5 x 15 (mm) balloon 90 (cm) guiding catheter
6-8F compatible marker (T-100 only)
Hemostasis hard stop principle
Trapping Balloon
Required pressure for trapping 6 ATM
Trapping Devices
© IMDS
Shaft stopper Trapper
Shaft stopper TrapIt
TrapIt trapping mechanism does not
interfere with devices in the guiding
catheter- no increase in profile. New
devices can be entered in guiding
catheter without interference.
Shaft stop profile 10F ~ 3 (mm)
Trapper trapping mechanism uses high shaft
profile (10F) hemostasis valve blockage. High
profile can potentially interfere with devices in
guiding catheter and limits entry of new
devices.
Overview
OTW catheters with dual-layer coil + braid shaft
design for superior flexibility & torque for
delivery over 0.014" wires
56
Turnpike
superior tracking
in tortuous vessels
Turnpike Spiral
rotational assistance,
trackability
Turnpike Gold
metallic tip for
enhanced advancement
Turnpike LP
low profile & flexible
for extreme tortuosity
OTW distal exit guidewire angle lift comparison
Guide wire exit
angle
6-7 degree
3-4 degree
6-7 degree

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Dedicated CTO kit: microcatheters, balloons, adjunctive devices

  • 1. Kambis Mashayekhi University Heartcenter Bad Krozingen Euro CTO Club 2017: Friday 13h40 Dedicated CTO kit: microcatheters, balloons, adjunctive devices
  • 2. 2 Microcatheters for antegrade CTO approach Finecross 130/150cm Corsair Pro 135/150cm M-Cath 135cm Turnpike Spiral 135/150cm
  • 3. Microcatheters for antegrade CTO approach Less Guiding Back up Ostial or very proximal lesions, planned ADR Good Guiding Back up Not very calcified CTO lesions Finecross M-Cath Corsair Turnpike Spiral Rotatable MCPushable MC
  • 4. Turnpike Spiral - active support
  • 5. Turnpike Spiral - active support
  • 6. Microcatheters for septal crossing Corsair 150cm Turnpike 150cm
  • 7. Microcatheters for epicardial crossing Finecross 150cm
  • 8. Microcatheters for retrograde CTO approach Septal Crossing Epicardial Crossing Rotatable MC Low profile MC Corsair Turnpike >1,5mm < 1,5mm Finecross Turnpike LP Caravel Mirco 14
  • 9. Septal crossing with channel dilatator Thanks to Nicolas Boudou for the great organization and invitation of the JIF CTO in Toulouse 2016
  • 10. Corsair Pro: push and rotation force
  • 11. Over-rotation of MC in calcified lesion: Wire and MC entrapment: Corsair-TIP with Confianza 12g
  • 12. Complications in collaterals – Over-rotating the MC Do not force an over-rotation of the MC in tortuosity www.youtube.com: Case 64: Manual of CTO Interventions, 2nd edition
  • 13. 1) Do not use a MC which you have to push in tiny collaterals and severe angulations 2) A rotatable MC may be safer (Turnpike LP, Corsair) Complications in collaterals – Pushing MC in tortuosity
  • 15. Tip Configurations SuperCross Angled Tips – 130cm & 150cm lengths with 45°, 90° & 120° angles – XT = extended tip lengthened from 0.65mm to 1.75mm to achieve more secure cannulation – 130cm & 150cm lengths
  • 16. Angled Tip - RCX-CTO 09/17
  • 17. Angled Tip - RCX-CTO 09/17
  • 18. 0,48 (mm) 2.3F Round shaft 0.97 (mm) crossing profileOval shaft Minor axis 2.3F (0.75 (mm)) = Crossing profile Major axis 3.3F (1.1 (mm)) Duallumen Microcatheters Round shaft 1.2 (mm) crossing profile © IMDS 2017 6.5 mm 3.3F
  • 19. Reverse wire technique 1. 2. 3. 5. 6. Bifurcation CTO wiring Dual lumen applications Wiring acute angulated bifurcations Parallel wiring technique 4.
  • 20. Trapping Devices © IMDS Shaft stopper Trapper Shaft stopper TrapIt
  • 21. Trapping Balloon compatibility chart © IMDS Product TrapIt Guiding Catheter compatibility Single Lumen Micro catheters NHancer Pro X; Corsair, FineCross, Caravelle, Turnpike 6F Dual Lumen Micro catheters NHancer Rx; FineDuo; Crusade 6F Dual Lumen Micro catheters TwinPass Torque 7F Stingray LP CTO Re-Entry System 6F
  • 22. Usefulness of the Shaft Stopper
  • 23. Usefulness of the Shaft Stopper
  • 25. Design Balloon 0.6 x 5 (mm) 30 ATM rated Shaft OD ≤ 1.5F High push shaft Best in class shaft profile 5. Scoring design Short Rx section Guidewire used as scoring element Tip Low profile High penetration 95 cm and 105 cm exit markers
  • 26. Calcified RCX 13.09.2017 After Scoring with Blimp 30 ATM, Finecross, Rotawire, 1,5mburr
  • 27. Calcified RCX 13.09.2017 Hornet 14g, Finecross couldn’t pass, Scoring with Blimp 30 ATM
  • 29. Fibrotic tissue: Laser Calcification: Rotablation Uncrossable and calcified lesion:
  • 30. Ultra-high pressure balloon: OPN NC (SIS Medical) 2 balloon layers Manometer for high-pressure inflation 2,45 F
  • 31. 60% 50% 25% 36% 15% 14% 0 10 20 30 40 50 60 70 Max. pressure pre Max. pressure post 35 - 40 atm 41 - 45 atm 46 - 50 atm Maximum pressures for pre- and post-dilatation 10/2010 – 10/2015 n=176 patients n=238 OPN NC balloons [%] Data collection by Achim Büttner – Heartcenter Bad Krozingen
  • 32. Rotablator assisted revers CART NC-Balloon at 24 ATM
  • 33. Rotablator assisted revers CART 1,5mm burr
  • 34. NC Balloon 26 atm SIS Medical 45 atm Ultra high pressure balloon
  • 35. SIS Medical 50 atm SIS Medical 55 atm Ultra high pressure balloon
  • 37. NovaCross MC Walsh S et al., Efficacy and Safety of Novel NovaCross Microcatheter for Chronic Total Occlusions: First-in-Human Study, J Invasive Cardiol, 2016 Mar.
  • 38. CenterCross and MultiCross Jalal S et al, Novel CenterCross and MultiCross devices for the treatment of infrainguinal chronictotal occlusions: initial single- centre experience. EuroIntervention. 2016 Jan
  • 39. Snares EnSnare Merit Medical One Snare (2mm- 35mm) Merit Medical 150 cm 6F compatible Vascular Solutions
  • 40. Snaring in ostial RCA – CTO (2x6F unlar/radial)
  • 41. Snaring: “KAM-Snare” Wire Externalization Techniques for Retrograde Percutaneous Coronary Interventions of Chronic Total Occlusions, K. Mashayekhi et al. 2017, accepted in EuroIntervention
  • 42. Snaring: “KAM-Snare” Wire Externalization Techniques for Retrograde Percutaneous Coronary Interventions of Chronic Total Occlusions, K. Mashayekhi et al. 2017; accepted in EuroIntervention
  • 43. Avoid blood loss !! OKAY II
  • 44. • Microcatheters for antegrade approach and septal or epicardial crossing • Duallumen catheters • Low profil balloons • Rotablator • Ultra high pressure balloons • Snares • Special Y-connectors to avoid blood lost CTO toolkit
  • 45. Thank you for your attention!
  • 47. CTO Wiring Back up force Calcification and tortuosity Subintimal tracking Finecross 1,8F Very good feedback on the wire tip, due to low resistance in the MC Low active back up, good push Very flexible shaft, low profile, Crossing success depending on guiding back up force Requires almost very good guiding back up Corsair 2,6F Over-rotation of the wire and MC may cause wire and device entrapment Very good active back up Attention! Do not over-rotate Very good performance in subintimal; Power knuckle may cause tip prolaps Turnpike Spiral 2,9F Over-rotation may cause device entrapment Best active back up Excellent in fibrotic tissues, like In-Stent- Occlusion Excellent back up in subintimal space Antegrade Microcatheter
  • 48. The is a CTO Scoring Balloon intended to create Initial Opening in heavy calcified/ fibrotic occlusions where the primary crossing is an issue.
  • 49. Jalal S et al, Novel CenterCross and MultiCross devices for the treatment of infrainguinal chronictotal occlusions: initial single- centre experience. EuroIntervention. 2016 Jan
  • 50.
  • 53. © IMDS Trapping mechanism comparison Unique patented shaft bend mechanism Telescopic shaft stop mechanism Two product codes guiding catheter length specific One product code not guiding catheter length specific No trapping mechanism setup required Trapping mechanism (telescopic) need to be adjusted to guiding catheter length Free insertion and retraction of devices into guiding catheter Restricted inserion and retraction of devices into guiding catheter
  • 54. © IMDS Radiopaque Shaft profile ≤2F Hemostasis valve Hub tip hard stop 2.5 x 15 (mm) balloon 90 (cm) guiding catheter 6-8F compatible marker (T-100 only) Hemostasis hard stop principle Trapping Balloon Required pressure for trapping 6 ATM
  • 55. Trapping Devices © IMDS Shaft stopper Trapper Shaft stopper TrapIt TrapIt trapping mechanism does not interfere with devices in the guiding catheter- no increase in profile. New devices can be entered in guiding catheter without interference. Shaft stop profile 10F ~ 3 (mm) Trapper trapping mechanism uses high shaft profile (10F) hemostasis valve blockage. High profile can potentially interfere with devices in guiding catheter and limits entry of new devices.
  • 56. Overview OTW catheters with dual-layer coil + braid shaft design for superior flexibility & torque for delivery over 0.014" wires 56 Turnpike superior tracking in tortuous vessels Turnpike Spiral rotational assistance, trackability Turnpike Gold metallic tip for enhanced advancement Turnpike LP low profile & flexible for extreme tortuosity
  • 57. OTW distal exit guidewire angle lift comparison Guide wire exit angle 6-7 degree 3-4 degree 6-7 degree