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hct_Prelims.qxp 6/4/2007 7:04 PM Page i

Handbook of Chronic Total

Occlusions
hct_Prelims.qxp 6/4/2007 7:04 PM Page ii
hct_Prelims.qxp 6/4/2007 7:04 PM Page iii

Handbook of Chronic Total

Occlusions

Edited by
George D Dangas MD PhD
Associate Professor of Medicine
Director of Postgraduate Training
Program Director, Interventional Cardiology
Columbia University Medical Center
Cardiovascular Research Foundation
New York, NY
USA
Roxana Mehran MD
Associate Professor of Medicine
Director, Outcomes Research
Data Coordination and Analysis Center
for Interventional Vascular Therapy
Columbia University Medical Center
Cardiovascular Research Foundation
New York, NY
USA
Jeffrey W Moses MD
Professor of Medicine
Director, Center for Interventional Vascular Therapy
Columbia University Medical Center
Cardiovascular Research Foundation
New York, NY
USA

Foreword by
Martin B Leon
hct_Prelims.qxp 6/4/2007 7:04 PM Page iv

©2007 Informa UK Ltd

First published in the United Kingdom in 2007 by Informa Healthcare, Telephone House, 69-77
Paul Street, London EC2A 4LQ. Informa Healthcare is a trading division of Informa UK Ltd.
Registered Office: 37/41 Mortimer Street, London W1T 3JH. Registered in England and Wales
number 1072954.

Tel: +44 (0)20 7017 5000

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All rights reserved. No part of this publication may be reproduced, stored in a retrieval system,
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Although every effort has been made to ensure that all owners of copyright material have been
acknowledged in this publication, we would be glad to acknowledge in subsequent reprints or
editions any omissions brought to our attention.

Although every effort has been made to ensure that drug doses and other information are
presented accurately in this publication, the ultimate responsibility rests with the prescribing
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consult the prescribing information or instructional material issued by the manufacturer.

A CIP record for this book is available from the British Library.
Library of Congress Cataloging-in-Publication Data

Data available on application

ISBN-10: 1 84184 624 4

ISBN-13: 978 1 84184 624 8

Distributed in North and South America by

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Printed and bound by Replika Press Pvt Ltd.
hct_Prelims.qxp 6/4/2007 7:04 PM Page v

Contents

List of Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

Foreword
Martin B Leon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi

1 Patient selection and general approach to CTO revascularization

Charles Perry and George D Dangas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2 Guidewire techniques and technologies: hydrophilic versus stiff
wire selection
Garrett B Wong, Matthew J Price, and Paul S Teirstein. . . . . . . . . . . . . . . . . . . . 11
3 Advanced techniques for antegrade advancement of wires
Etsuo Tsuchikane . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
4 Retrograde and bilateral techniques
Jean-François Surmely and Osamu Katoh. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
5 Subintimal tracking and reentry: the STAR technique
Antonio Colombo and Goran Stankovic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
6 Technical options for uncrossable lesions
Masahiko Ochiai . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
7 Rotational atherectomy
Mark Reisman . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
8 Role of the CROSSER Catheter
Mark Reisman . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
9 The role of fibrinolytic therapy in the management of
chronic total occlusions
Amr E Abbas and William W O’Neill . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
10 Drug-eluting stents for chronic total occlusions: the European
experience
Angela Hoye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
11 Drug-eluting stents for chronic total occlusions: the North American
and Asian experience
David E Kandzari . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
hct_Prelims.qxp 6/4/2007 7:04 PM Page vi

vi Contents

12 Prevention of complications: when to stop–retry–redirect to

other therapy
Neil K Goyal and Jeffrey W Moses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
13 Complications related to radiation and contrast
media exposure
Masashi Kimura, Eugenia Nikolsky, Stephen Balter, and
Roxana Mehran . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
14 Procedural and technical complications
Masashi Kimura, Antonio Colombo, Eugenia Nikolsky,
Etsuo Tsuchikane, and George D Dangas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
15 Peripheral CTO recanalization and revascularization techniques
Neil K Goyal, George D Dangas, and William Gray . . . . . . . . . . . . . . . . . . . . . . 163
16 Role of excimer laser
Steven R Bailey. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
17 Role of antegrade blunt dissection for coronary and
peripheral chronic total occlusions
Patrick L Whitlow and Matthew Selmon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
18 Role of an optical reflectometry and radiofrequency ablation
device: coronary chronic total occlusions
Gregory A Braden and George D Dangas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
19 Role of an optical reflectometry and radiofrequency ablation
device: peripheral chronic total occlusions
M Ishti Ali and Richard Heuser. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
20 Tackling chronic total occlusions: training standards
and recommendations
Ajay J Kirtane and George D Dangas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
hct_Prelims.qxp 6/4/2007 7:04 PM Page vii

Contributors

Amr E Abbas MD Neil K Goyal MD MPH

William Beaumont Hospital Columbia University Medical Center
Royal Oak, MI New York, NY
USA USA

M Ishti Ali MD William Gray MD

St Joseph’s Hospital and Medical Columbia University Medical Center
Center Cardiovascular Research Foundation
Phoenix Heart Center New York, NY
Phoenix, AZ USA
USA
Richard Heuser MD
Steven R Bailey MD St Joseph’s Hospital and Medical
University of Texas Health Science Center
Center at San Antonio Phoenix Heart Center
San Antonio, TX Phoenix, Arizona
USA USA

Stephen Balter PhD Angela Hoye MB ChB PhD MRCP

New York-Presbyterian Hospital Department of Cardiology
Columbia University Medical Center Castle Hill Hospital
New York, NY Kingston-upon-Hull
USA UK

Gregory A Braden MD David E Kandzari MD

Cardiology Specialists of North Duke Clinical Research Institute
Carolina Chapel Hill, NC
Winston-Salem, North Carolina USA
USA

Antonio Colombo MD Osamu Katoh MD

Columbus Hospital/San Raffaele Toyohashi Heart Center
Hospital Toyohashi,
Milan Aichi
Italy Japan

George D Dangas MD PhD Masashi Kimura MD PhD

Columbia University Medical Center Cardiovascular Research
Cardiovascular Research Foundation Foundation
New York, NY New York, NY
USA USA
hct_Prelims.qxp 6/4/2007 7:04 PM Page viii

viii List of Contributors

Ajay J Kirtane MD Mark Reisman MD

Columbia University Medical Center Swedish Heart Institute
Cardiovascular Research Foundation Seattle, Washington
New York, NY USA
USA
Matthew Selmon
Roxana Mehran MD The Cleveland Clinic Foundation
Columbia University Medical Center Cleveland, Ohio
Cardiovascular Research Foundation USA
New York, NY
USA Goran Stankovic MD
Institute for Cardiovascular Disease
Jeffrey W Moses MD Clinical Center of Serbia
Columbia University Medical Center Belgrade
Cardiovascular Research Foundation Serbia
New York, NY
USA Jean-François Surmely MD
Swiss Cardiovascular Center
Eugenia Nikolsky MD PhD Bem University
University of Haifa Bem
Haifa Switzerland
Israel
Paul S Teirstein MD
Masahiko Ochiai MD PhD Division of Cardiology
Professor, Division of Cardiology Scripps Clinic
and Cardiovascular Surgery La Jolla, California
Showa University Northern USA
Yokohama Hospital
Yokohama Etsuo Tsuchikane MD PhD
Kanagawa Toyohashi Heart Center
Japan Toyohashi
Aichi
William W O’Neill MD Japan
University of Miami
Florida Patrick L Whitlow MD
USA The Cleveland Clinic Foundation
Cleveland, Ohio
Charles Perry MD MBA USA
Columbia University Medical Center
New York, NY Garrett B Wong MD
USA Division of Cardiology
Scripps Clinic
Matthew J Price MD La Jolla, California
Division of Cardiology USA
Scripps Clinic
La Jolla, California
USA
hct_Prelims.qxp 6/4/2007 7:04 PM Page ix

Foreword

The challenge of revascularizing chronic total coronary occlusions (CTO) has

plagued the practicing interventionalist since the inception of coronary angio-
plasty, almost three decades ago. The presence of a CTO remains the single most
frequent reason given for patient referral for coronary bypass surgery, as pre-
dictable revascularization success utilizing transcatheter techniques has been
disappointing and treatment site recurrence (restenosis and re-occlusion) has been
excessive. Nevertheless, there are growing data which indicate that successful
treatment of CTOs results in improved symptoms, prolonged life, increased left
ventricular function, and enhanced quality of life.
Importantly, significant changes have occurred over the past several
years which have stimulated an energized re-examination of CTO therapy. First,
the advent and use of drug-eluting stents has markedly reduced angiographic
and clinical recurrence after successful CTO recanalization, rendering these
difficult procedures more definitive with improved long-term patency. Second,
advanced new guidewire techniques have provoked the interest of interven-
tionalists and have increased initial CTO guidewire crossing success. Finally,
several innovative technology solutions have been proposed and are being tested
which offer the promise of further procedural enhancements, allowing the
average interventional operator a greater opportunity for safe and effective
CTO therapy.
Considering these dynamic changes in the CTO landscape, it is especially
timely to applaud the presentation of this comprehensive Handbook of Chronic
Total Occlusions. This expertly organized and carefully written handbook repre-
sents the collective wisdom of a broad cross-section of CTO treatment experts
from around the world. The breadth of topics covered includes general princi-
ples of CTO therapy, advanced new guidewire techniques (often pioneered by
our Asia-Pacific colleagues), the latest results after drug-eluting stents, and inno-
vative treatment modalities such as radiofrequency ablation, ultrasonic recanal-
ization, excimer laser angioplasty, and blunt dissection techniques. Important
areas which address the safety of CTO therapy are also extensively discussed,
including specific angiographic and clinical complications during CTO procedures
and the more subtle considerations of excessive X-ray exposure and increased
radiocontrast volume.
It is particularly noteworthy that this handbook was designed and written
specifically for the practicing interventional cardiologist with a special interest
in CTO therapy. The content emphasizes operator techniques, clinical treat-
ment issues, and practical case-based scenarios. Undoubtedly, the assimilation
of practical materials amassed in this CTO handbook will assist interventional
hct_Prelims.qxp 6/4/2007 7:04 PM Page x

x Foreword

cardiologists in improving their technical skills, and most importantly, the

quality of clinical care in patients with complex coronary disease. I heartily
recommend this definitive handbook of CTO therapy and expect that it will
quickly gain status as a ‘must read’ text in the subspecialty of interventional
cardiology.

Martin B Leon MD
Professor of Medicine
Columbia University Medical Center
New York, NY
USA
hct_Prelims.qxp 6/4/2007 7:04 PM Page xi

Preface

Remarkable progress has been achieved over the past few years in the area of
chronic total occlusion (CTO) revascularization. Occurrence of a CTO within a
patient’s coronary anatomy has been traditionally considered with skepticism
from interventional cardiologists. This has been due to the indications and out-
comes of percutaneous revascularization as well as the technical difficulties
encountered in CTO procedures. Several advances have occurred in all these
areas and we had the pleasure to work with a team of worldwide experts in order
to present them in a concise and practical way through the present handbook.
The first part of this handbook presents the thought process regarding clinical
indications, angiographic stratification of technical difficulty, and the overall
planning required before a CTO revascularization in undertaken. The basis inter-
ventional concepts of vascular access, guide catheter and wire selection, and
manipulation are presented. This part is very critical, since successful wire crossing
is the most important step for subsequent equipment passage and a successful
procedure. Presentation of these topics extends throughout many chapters, all of
which include many case examples with step-by-step explanations of the tech-
niques undertaken. All these three topics are interrelated, since any one of them can
ultimately affect wire crossing; all chapters clearly discuss alternative approaches,
and corrective pathways and justify the technical options demonstrated in the
case examples in a way to promote the necessary synergy among them.
Special attention has been paid to the active support, intravascular ultrasound
guidance, and retrograde techniques that have been pioneered by Japanese oper-
ators over the past few years. We believe that the careful selection of examples
and the painstaking instructions through every single detail of technical princi-
ples and related ‘tips and tricks’ are seminal to CTO procedure teaching.
Following successful crossing, it is still possible that subsequent equipment
may not be able to advance through the occlusion. Succeeding in this step is
equally important to guidewire crossing of the CTO, and is therefore analyzed at
length in this handbook. The instruction provided starts from the importance of
vascular access and guide catheter selection, and proceeds to active support tech-
niques (e.g. anchoring balloon) and use of special catheters (e.g. Tornus, excimer
laser, etc.), always using telling case examples. The issue of debulking is also pre-
sented, including indications and technical suggestions. Finally, the role of drug-
eluting stent implantation is presented from two authors in order to best represent
the global thought process regarding the long-term procedural outcome.
An operator tackling a CTO lesion needs to be prepared throughout the pro-
cedure to deal with certain specific complications. Steps towards avoiding
complications by appropriately choosing when to interrupt a CTO procedure
(and when to retry later) are discussed in a dedicated chapter. A more rounded
hct_Prelims.qxp 6/4/2007 7:04 PM Page xii

xii Preface

review of CTO-specific complications includes many technical details on the

ways to manage various types of perforations, as well as the reversal of anticoag-
ulation issues.
Since CTO lesions can also be encountered in the peripheral vascular circula-
tion, we have included dedicated chapters on iliofemoral occlusions, with techni-
cal details both on wire crossing as well as on appropriate use of assisting devices
(e.g. for distal lumen reentry), again with step-by-step instruction through many
selected case examples.
Several ‘niche’ devices for both coronary and peripheral CTO lesions are
presented concisely in dedicated chapters that analyze the current indications,
device description, and their technical details utilized in the case demonstrations.
Finally, our general approach for CTO procedure training is outlined with
respect to program and individual requirements. Traditionally, training for CTO
has been difficult; recent advances can be disseminated though participation in
focused courses, preceptorship programs, wider inclusion of CTO in the formal
training curriculum, use of simulation, and the work towards building a ‘CTO
team’ of doctors, assisting physicians (trainees) nurses, and technologists within
the cardiac catheterization laboratory.
Clearly, we could have expanded each one of the above topics to a much
greater length. However, we felt that the concise handbook type of presentation
was the most appropriate for the first introduction of this entire subject to the
busy interventional cardiology community. We hope that the readers find that
we lived up to their expectations.

George D Dangas
Roxana Mehran
Jeffrey W Moses
HCT_CH01.qxp 6/4/2007 6:35 PM Page 1

1
Patient selection and
general approach to CTO
revascularization
Charles Perry and George D Dangas

Clinical outcomes ● Patient selection ● General approach ● Vascular access

● After successful wire crossing

A considerable variety of unsettled issues surround the field of chronic total

occlusions (CTOs) as a target for revascularization procedures. There is continual
refinement of the following issues: establishment of robust indications, optimal
technique, and the ultimate impact of revascularization on patient outcomes. An
international expert consensus document has recently addressed these subjects.1,2
Although other types of revascularization procedures have been established
over time based on early results, and then expanded through new indications
based on long-term data, this has not been the case for approaching CTO lesions.
Difficulty achieving predictable procedural success, together with duration of
CTO procedures, (with implications for optimal laboratory time personnel),
equipment resource utilization, radiation exposure, and complications, have all
posed a unique set of hurdles for routine CTO targeting. Although CTO lesions
are observed in approximately one-third of diagnostic coronary arteriograms,
recanalization is attempted in less than 15% of patients undergoing percutaneous
coronary intervention (PCI).3,4 Indeed, the most common reason for referral to
bypass surgery or exclusion from clinical studies comparing outcomes of angio-
plasty to bypass surgery has been the presence of a CTO.5,6

CLINICAL OUTCOMES
In a large meta-analysis of 4400 patients, Freed et al demonstrated a long-term
success rate of 69% in patients after CTO angioplasty, with a major acute cardio-
vascular event rate of 2%.7 Long-term success was defined as restriction of lower
recurrence of ischemia, improvement of left ventricular function, and higher
event-free survival rate. The majority of failures (80%) were free of complications
and due to an inability to cross the lesion with a wire, a fact which emphasizes the
HCT_CH01.qxp 6/4/2007 6:35 PM Page 2

2 Handbook of Chronic Total Occlusions

importance of appropriate patient and material selection. The SICCO trials

demonstrated favorable results with stent implantation after successful recanal-
ization; the cardiovascular event rate during 3 years of follow-up was found to
be 24% in patients with stents, compared with 59% in conventional angioplasty
alone.8
The Mid-America Heart Institute Study,9 British Columbia Cardiac Registry,10
and Total Occlusion Angioplasty Study (TOAST-GISE)11 reported on the clinical
impact of successful percutaneous CTO revascularization on long-term clinical
outcome. The Mid-America Heart Study retrospectively analyzed a consecutive
series of 2007 patients over 20 years (1980–1999) of performing PCI for non-acute
coronary occlusions. Importantly, long-term survival was similar in patients with
successful CTO recanalization compared with a matched cohort of patients under-
going successful angioplasty of non-occluded lesions, and significantly longer
than in patients where attempted CTO revascularization failed (10-year sur-
vival 74% with CTO success vs 65% with CTO failure; p ⬍0.001). By multivariate
analysis, failure to successfully recanalize the CTO was an independent predictor
of mortality.
The British Columbia Cardiac Registry studied 1458 patients with CTOs, which
constituted 15% of the attempted revascularizations. Successful percutaneous
revascularization of CTO was not only associated with increased survival and
reduced need for surgical revascularization over 7 years of follow-up but also
with a 56% relative reduction in late mortality.
In the prospective TOAST-GISE of 390 CTO (in 369 patients), a successful PCI
was associated with: a reduced 12-month incidence of cardiac death or myocar-
dial infarction (1.1% vs 7.2%), a reduced need for coronary artery bypass surgery
(2.5% vs 15.7%) and greater freedom from angina (89% vs 75%).
In the overall study population, the only factor associated with enhanced 1-year
event-free survival was successful CTO recanalization (odds ratio⫽0.24;
p ⬍0.018).

PATIENT SELECTION
The interventional cardiologist must weigh the individual risks and benefits for
each patient when deciding to attempt PCI of a CTO vs two other alternatives:
aortocoronary bypass surgery or medical therapy. Clinical, angiographic, and tech-
nical considerations must be considered in combination.
From a clinical point of view, age, symptom severity, associated comorbidities
(e.g. diabetes mellitus and chronic renal insufficiency), and overall functional
status are major determinants of treatment strategy. Angiographically, the extent
and complexity of coronary artery disease, likelihood for complete revascu-
larization, and the presence and degree of valvular heart disease and left ventric-
ular dysfunction are all very important factors. The technical probability of
achieving successful recanalization of the PCI without complications, as well as the
anticipated restenosis rate, must also be heavily weighed in the decision-making
process.2
When the CTO is the lone obstructive lesion in the coronary vasculature tree,
there are three conditions which, when present, favor PCI. The first condition is
the presence of symptoms. An average chronic total occlusion with well-developed
HCT_CH01.qxp 6/4/2007 6:35 PM Page 3

Patient selection and general approach 3

collaterals is hemodynamically similar to a 90% coronary stenosis without collat-

eral vessels.12 In a consecutive cohort of 127 patients with visible collaterals and
successful CTO recanalization, Werner et al showed that collateral function,
measured by intracoronary Doppler and pressure wire indices, was similar in
patients with and without post-PCI regional left ventricular functional recov-
ery.13 Therefore, although considerable recovery of ventricular function after
recanalization can be expected (occurring in 39% of patients with baseline ven-
tricular dysfunction in this series), it is independent of invasively determined
parameters of collateral function. Coronary collateral development is not closely
linked to myocardial viability but is rather the result of the recruitment of preex-
isting interarterial connections. When successful, the majority of patients with suc-
cessful CTO recanalization can expect significant reduction or complete resolution
of anginal symptoms. In a sample of 10 studies involving 829 patients total, Puma
et al found symptom relief is 70% for patients who experienced successful recanal-
ization of the CTO vs only 31% when the attempt was unsuccessful.
The second condition to consider is the presence of viable myocardium. Recovery
of left ventricular function in chronically ischemic myocardium depends on the
presence of hibernating viable myocardium. In a cohort of 97 patients with CTO,
Sirnes et al demonstrated that successful recanalization improved left ventricular
ejection fraction by 8.1% (rising from 62% to 67%), with the greatest improve-
ment of 10% occurring in those patients with left anterior descending artery dis-
ease.14 Additionally, they showed that the Wall Motion Severity Index (WMSI),
a marker of global left ventricular dysfunction, also increased after CTO recanal-
ization. The WMSI is obtained by averaging the wall motion of all the individual
(analyzable) myocardial segments (values: ⫺1 ⫽ dyskinesis, 0 ⫽ akinesis, 1 ⫽
hypokinesis, and 2 ⫽ normal).15 It is notable that the history of MI, the dura-
tion of an occlusion, and the incidence of a non-occlusive restenosis had no
influence on left ventricular recovery, whereas reocclusion did have an adverse
influence.13
Finally, the probability of success should steer an operator towards perform-
ing PCI in a CTO when the likelihood of success is moderate to high (more than
60%) and the likelihood of complications is low (i.e. anticipated risk of death
⬍1% and MI ⬍5%).16 Should the PCI attempt prove unsuccessful, further man-
agement will depend on the symptomatic status and the extent of jeopardized
ischemic myocardium. The operator should therefore be very familiar with the
predictors of success when performing PCI of a CTO. Although each condition in
Table 1.1 is an independent predictor of success or failure, several factors typi-
cally coexist.
Bridging collaterals, which are well-developed vasa vasorum unique to CTO
lesions, are proportional to the duration of the CTO and therefore are more com-
mon in lesions older than 3 months. If antegrade flow is observed beyond the
CTO, it is essential to differentiate the cause as microchannels in the true lumen vs
perivascular bridging collaterals: the first is a predictor of success and defines a
functional CTO (no longer considered a ‘true’ CTO), the latter is a predictor of
an unsuccessful procedure. The distinction can usually be made by obtaining
multiple angiographic projections of the occlusion; however, it sometimes only
becomes apparent at the time of PCI. Extensive bridging collaterals that form a
‘caput medusae’ around the occluded vessel are generally unsuitable for PCI
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4 Handbook of Chronic Total Occlusions

Table 1.1 Predictors of success and failure in PCI of CTO

Predictors of success Predictors of failure

Duration ⬍3 months Duration ⬎3 months
Antegrade flow (⫹) Antegrade flow (⫺)
Tapered morphology (⫹) Tapered morphology (⫺)
Bridging collaterals (⫺) Bridging collaterals (⫹)
Side branch (⫺) Side branch (⫹)
Lesion length ⬍15 mm Lesion length ⬎15 mm
Single-vessel disease Multivessel disease
PCI, percutaneous coronary intervention.

due to the very low success rate as well as high complication rate from perforation
of the fragile small collateral vessels. However, these classic unfavorable features
may no longer constitute unsurpassable hurdles with the employment of the
innovative technical approaches described in later chapters of this book. Indeed,
several experienced operators consider the absence of a visible distal vessel as
the only contraindication to a CTO attempt.
In patients with multivessel disease and one or more CTO lesions, the following
conditions suggest careful consideration of referral to bypass surgery in place of
attempting PCI: left main stem disease or occluded proximal left anterior descend-
ing artery supplying a viable anterior wall, complex triple vessel disease and
insulin-requiring diabetes mellitus; severe left ventricular dysfunction; chronic
kidney disease. Finally, multiple CTOs with low probability of success or high
probability of complication should be treated surgically.
Specifically for patients after a myocardial infarction, two recent trials examined
the older concept of “open-artery hypothesis.” According to their results,17–18 sus-
tained potency of an occluded artery can be achieved successfully with percuta-
neous revascularization. However, in a population that is clinically stable (without
significant ischemia of heart failure) and without residual myocardial viability
who are submitted to PCI of an occluded artery at least 3 days post-infarction, the
revascularization did not seem to confer clinically measurable benefit.

GENERAL APPROACH
Despite the outlined reservations, there has been a gradual increase in technical
and procedural success rates for percutaneous CTO recanalization over the last
10 years, as well as an increase in the number of CTO cases attempted. Importantly,
this has not been associated with a concomitant increase in adverse event rates,
probably related to improved equipment, procedural techniques, operator experi-
ence, and improved case selection.9 Available studies thus far have mostly followed
the case-control or cohort methodology. It is difficult to develop prospective, ran-
domized data in the context of an evolving technique and technological approach.

Case selection, angiographic views, and pharmacology

An individualized case selection is of paramount importance for PCI of a CTO.
As a general rule, operators should begin with straightforward cases (i.e. patients
without any unfavorable features as indicated in Table 1.1) and progressively
HCT_CH01.qxp 6/4/2007 6:35 PM Page 5

Patient selection and general approach 5

advance to more complex cases (right column of Table 1.1) as they gain compe-
tency. Before performing the procedure, it is essential to review the lesion from
multiple views in orthogonal projections. If optimal and detailed visualization
is not achieved with conventional angiography, the use of simultaneous ipsilat-
eral and contralateral injections is strongly recommended to define the occluded
vessel/stump anatomy, and the presence and orientation of side branches in
relation to the assumed true lumen course. It is essential to distinguish microchan-
nels in the CTO lumen, which can be easily perforated and should therefore not
be dilated. For the most experienced CTO operator, the only near contraindica-
tion to performing percutaneous recanalization of a CTO is the absence of a visible
distal vessel lumen (not even through retrograde collaterals).
The amount of contrast load should be thought of prior to the procedure. To
economize the amount of contrast used, contralateral injections can be performed
through an end-hole catheter inserted distally into the artery for very selective
angiography at less than 1 cc per injection. Although this represents the most sensi-
tive approach with respect to contrast media, it may not be advisable routinely due
to the risks of a stationary catheter in the distal part of the collateral-providing ves-
sel. For instance, proximal tortuosity and calcification may limit distal positioning
or significantly obstruct antegrade flow and increase thrombotic complications.
Since no CTO procedure is considered emergent, appropriate pretreatment with
clopidogrel (at least 6 hours prior, but ideally started 3–4 days before at 75 mg
daily) and oral aspirin 325 mg should be ensured. Initially, a bolus of 3000 units
unfractionated heparin should be administered intravenously or via the guiding
catheter; in case contralateral injections will be performed, it is advisable to admin-
ister the heparin through the catheter that engages the collateral-providing vessel,
especially if a distal indwelling catheter is anticipated. An activated clotting time
above 180 seconds is adequate during typical antegrade wire manipulations, but
additional heparin may be required for prolonged procedures and particularly if
a retrograde approach is followed with advancement of a static catheter system
in the collateral-providing vessel; in such cases, a higher activated clotting time
is necessary (above 250–300 seconds). When the wire has successfully crossed the
lesion and its position in the distal true lumen has been verified, additional
heparin should be given to reach an activated clotting time above 250 seconds and
a platelet GPIIb/IIIa inhibitor may then be given according to lesion complexity
and operator preference. Pharmacological treatment after PCI remains unchanged
from the standards applied for PCI performed in non-occlusive stenoses.

VASCULAR ACCESS
Preferred vascular access is usually through the femoral artery, utilizing an 8 Fr
guide for passive support, with smaller guides used to provide more maneuver-
ability or for shorter occlusions (in experienced hands). Larger guides, however,
provide the ability to introduce covered stents more easily should perforation
occur, a possibility that must be entertained for any CTO. If a second catheter is
needed for contralateral injections, a 4–6 Fr catheter can be inserted into the
opposite femoral artery or either radial artery. Access from the ipsilateral groin
using a 4 Fr catheter may also be an acceptable alternative by puncturing 1 cm
medially and distally to the previously placed sheath.19 When a guiding catheter
HCT_CH01.qxp 6/4/2007 6:35 PM Page 6

6 Handbook of Chronic Total Occlusions

no larger than 6 Fr is required, the distal vessel is visible from ipsilateral collateral
flow, and the location of the occlusion is mid or distal in the presence of otherwise
favorable anatomy, the radial artery may be an acceptable alternative for CTO
angioplasty by experienced radial access operators.20 If the retrograde approach
is entertained, then 8 Fr access should be obtained bilaterally.

Guiding catheter selection

Guiding catheters that provide extra back-up support and coaxial alignment
should be chosen. In native coronary arteries, a geometric or left Amplatz guide
usually offers the necessary support; however, if a Judkins or Multipurpose is used,
the ‘deep-seating’ maneuver can be employed to achieve the extra back-up. Two
guide catheters may be occasionally necessary to image the CTO with contralat-
eral injection, and two 8 Fr guiding catheters are required for the retrograde
approach.
For the left coronary system, extra back-up (XB)-type guiding catheters (Voda
especially for the circumflex, Extra BackUp especially for the left anterior descend-
ing, geometric left, left support) are preferable. Judkins-type guiding catheters
provide less support, are associated with reduced success with hard fibrocalcific
occlusions, and are not advisable.
For the right coronary artery, left Amplatz 0.75 or 1 (and exceptionally the #2
shape) generally provide the maximal passive support (especially with a superior
or shepherd’s crook takeoff). On the other hand, acceptable support can be pro-
vided in selected cases though hockey-stick shapes for the arteries with transverse
or slightly superior takeoffs, or Judkins shapes for inferiorly oriented vessels.
Routine use of Judkins, 3-dimensional, or Hockey Stick type catheters may allow
better coaxial alignment and wire steerability than Amplatz catheters, and support
can be enhanced by special techniques such as the anchoring balloon. In certain
cases, coaxial alignment may be more important than passive support (e.g. excessive
proximal tortuosity, proximal CTO, unusual location of calcified clefts). Typically,
right coronary guiding catheters should have side holes to allow perfusion of the
sinus node and conus branches during tight seating of the guide. Aggressive
manipulation of the guide catheter, or inadvertent deep intubation (which not
infrequently occurs with the Amplatz shape), may dissect the right coronary
ostium (often requiring stenting), a complication that should be anticipated and
recognized before guidewire removal.

Guidewire selection
This is fundamental for procedural success – the vast majority of failures occur
because an operator cannot cross the lesion. Wires designed for treating CTOs can
be divided into two groups: polymer-coated (hydrophilic or lubricious) guidewires
and non-coated coil guidewires; both groups also possess tapered and non-tapered
tips. Operators should become familiar with all wire types, and select certain wires
with which to become more comfortable, but still know how to selectively use a sig-
nificant number of additional wires that are part of the laboratory’s ‘CTO arma-
mentarium.’ Properties of the two wire types are outlined in Table 1.2; other
chapters analyze guidewire selection and techniques in detail.
 HCT_CH01.qxp

Table 1.2 Characteristics of guidewires for crossing a CTO

Manufacturer Wire Shaft and Tip stiffness, Additional Recommended

tip diameter (g) characteristicsa use(s)b
6/4/2007

Guidant High torque intermediate 0.014 inch 2–3 1

High torque standard 0.014 inch 4 a 2, 3
Cross-It 100 Shaft 0.014 inch 2 b 1, 4, 10
Tip 0.010 inch
Cross-It 200 Shaft 0.014 inch 3 b 2, 3, 10, 11, 12, 13
6:35 PM

Cross-It 300 Tip 0.010 inch 4

Cross-It 400 Shaft 0.014 inch 6 b 5, 8
Tip 0.010 inch
Whisper 0.014 inch 1 c, d 1, 4, 6, 7, 9, 10, 13
Page 7

Pilot 50 0.014 inch 2 c 1, 4, 6, 7, 9, 10, 13

Pilot 150 and 200 0.014 inch 4 and 6 e 3, 10, 11, 12, 13
Boston Scientific Choice PT and P2 0.014 inch 2 d, e, f 1, 4, 6, 7, 9, 10, 13
PT Graphix and Graphix P2 0.014 inch 3–4 d, e, f 3, 10, 11, 12, 13
Magnum 0.014 Shaft 0.014 inch 2 g 1, 13
Tip 0.7 mm
Asahi Intec Miracle Brothers 0.014 inch 3, 4, 5, 6, and 12 h, i 1 (3 g), 2, 11 (4.5–6 g),
and 2, 5, 8 (12 g); 14 (all)
Confianza and Confianza Pro Shaft 0.014 inch 9 and 12 b, i, j, k 2, 5, 8, 10
(Conquest and Conquest Pro) Tip 0.009 inch
Johnson and Johnson Shinobi 0.014 inch 2 c, f, l 9, 10, 11, 13
Shinobi Plus 0.014 inch 4 c, f, l 2, 3, 9, 10
Terumo Crosswire EX (platinum) 0.016 inch 2 e, m 1, 9, 10
Guidewire GT (gold)
a
a, caveat: wire entrapment possible in long and hard occlusions; b, tapered tip; c, lubricious tip with non-lubricious shaft; d, difficult to shape tip; e, lubricious shaft and tip;
f, poor tip memory; g, olive-shaped ball tip; h, excellent tactile feel; i, excellent torque control within occlusions and in long tortuous lesions; j, Pro version has hydrophilic
coating except at distal 1 mm of tip; k, Pro version moves through long occlusions with little resistance; l, caveat: subintimal passage common; m, 45 and 70 degree angles.
b
1, recent occlusions; 2, chronic occlusions ⬎12 months; 3, chronic in-stent occlusions; 4, functional occlusions; 5, long and hard occlusions; 6, subtotal stenoses; 7, acute
occlusions; 8, puncturing of fibrous cap; 9, tortuous anatomy; 10, intracoronary microchannels; 11, chronic occlusions ⬍12 months; 12, occluded saphenous vein grafts; 13,
recent in-stent occlusions; 14, best for parallel wiring due to excellent torque control. Reproduced from Stone et al,21 with permission.
Patient selection and general approach 7
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8 Handbook of Chronic Total Occlusions

AFTER SUCCESSFUL WIRE CROSSING

After passing both the stiff guidewire (non-coated or hydrophilic) and an
over-the-wire balloon dilatation catheter through the CTO into the distal lumen,
the stiff wire should be immediately withdrawn and replaced with a floppy-tipped
non-coated wire to minimize the risk of distal perforation or dissection. Significant
problems can arise if the 1.5 mm short balloon cannot be advanced over the wire.
This situation calls for additional guide support; since change of a guide catheter
over the crossing wire would probably threaten the distal wire position, active
support should be attempted using the anchor balloon at a side branch. If this is
not effective, an attempt to ablate the lesion with the smallest size (0.7) laser
catheter could be attempted, or use of tornus device can be selected. In excep-
tional cases, the balloon cannot be advanced even over a stiff wire introduced
through the tornus. In such cases, it is possible to reinsert the tornus and then
exchange the wire for the rota-extra-support and perform rotational atherec-
tomy with the 1.25 burr. All these options are analyzed in dedicated chapters.
After successful dilation of the occlusion, attention must be focused on the
entire vessel. Intracoronary administration of nitroglycerin is strongly advised to
maximize vasodilation of the chronically underperfused territory. Appropriate
predilation should then be performed at all sites that have obstructive lesions,
probably including the entire proximal vessel due to the frequently encountered
difficulty of advancing long drug-eluting stents through a diseased proximal vessel.
If necessary, intravascular ultrasound interrogation may clarify the vessel size and
the entire segment length. Finally, drug-eluting stents are recommended to obtain
the maximum acute gain and the lowest late loss, since CTO lesions are thought
to have exaggerated neointimal proliferative response.21–23
At the conclusion of the case, at least one femoral access site can be closed with
a device. Closure device choice should be carefully considered if the procedure
was unsuccessful and another attempt is planned.
In reviewing several previously attempted CTOs, we have developed the anec-
dotal observation that a few months of dual antiplatelet therapy can facilitate
thrombus resolution and new microchannels can develop after healing of the dis-
sections left at the end of the original procedure that may ultimately facilitate the
second attempt. The decision-making process regarding continuation of long CTO
procedures vs opting for a future reattempt is discussed in a dedicated chapter.

REFERENCES
1. Stone GW, Reifart NJ, Moussa I, et al. Percutaneous recanalization of chronically occluded
coronary arteries: a consensus document: part I. Circulation 2005; 112:2364–72.
2. Stone GW, Reifart NJ, Moussa I, et al. Percutaneous recanalization of chronically occluded
coronary arteries: a consensus document: part II. Circulation 2005; 112:2530–7.
3. Anderson HV, Shaw RE, Brindis RG, et al. A contemporary overview of percutaneous coro-
nary interventions. The American College of Cardiology–National Cardiovascular Data
Registry (ACC–NCDR). J Am Coll Cardiol 2002; 39(7):1096–103.
4. Srinivas VS, Brooks MM, Detre KM, et al. Contemporary percutaneous coronary interven-
tion versus balloon angioplasty for multivessel coronary artery disease. Circulation 2002;
106(13):1627–33.
5. King SB 3rd, Lembo NJ, Weintraub WS, et al. A randomized trial comparing coronary
angioplasty with coronary bypass surgery. N Engl J Med 1994; 331:1044–50.
HCT_CH01.qxp 6/4/2007 6:35 PM Page 9

Patient selection and general approach 9

6. Bourassa MG, Roubin GS, Detre KM, et al. Bypass Angioplasty Revascularization
Investigation: patient screening, selection, and recruitment. Am J Cardiol 1995; 75:3C–8C.
7. Freed J, et al. Meta-analysis of chronic total occlusion PTCA outcome. In: Chevalier
B, Royer T, Guyton Ph, Glatt B, eds. Chronic Total Occlusions. Paris Course on Revascularization
2001, Marco J, ed, Europa edition, Paris 2001:127–42.
8. Sirnes PA, Golf S, Myreng Y, et al. Stenting in Chronic Coronary Occlusion (SICCO): a
randomized, controlled trial of adding stent implantation after successful angioplasty.
J Am Coll Cardiol 1996; 28(6):1444–51.
9. Suero JA, Marso SP, Jones PG, et al. Procedural outcomes and long-term survival among
patients undergoing percutaneous coronary intervention of a chronic total occlusion in
native coronary arteries: a 20-year experience. J Am Coll Cardiol 2001; 38:409–14.
10. Ramanathan K, Gao M, Nogareda GJ, et al. Successful percutaneous recanalization of a non-
acute occluded coronary artery predicts clinical outcomes and survival. Circulation, 2001;
104:II–415.
11. Olivari Z, Rubartelli P, Piscione F, et al. for the TOAST-GISE Investigators: data from a
multicenter, prospective, observational study (TOASTGISE). J Am Coll Cardiol 2003;
41:1672–8.
12. Flameng W, Schwarz F, Hehrlein FW, et al. Intraoperative evaluation of the functional
significance of coronary collateral vessels in patients with coronary artery disease. Am J Cardiol
1978; 42:187–92.
13. Werner GS, Surber R, Kuethe F, et al. Collaterals and the recovery of left ventricular function
after recanalization of a chronic total coronary occlusion. Am Heart J 2005; 149(1):129–37.
14. Sirnes PA, Myreng Y, Molstad P, Bonarjee V, Golf S. Improvement of left ventricular ejection
fraction and wall motion after successful recanalization of chronic coronary occlusions. Eur
Heart J 1998; 19:273–81.
15. Jensen-Urstad K, Bouvier F, Hojer J, et al. Comparison of different echocardiographic methods
with radionuclide imaging for measuring left ventricular ejection fraction during acute
myocardial infarction treated by thrombolytic therapy. Am J Cardiol 1998; 81:538–44.
16. Kereiakes DJ, Selmon MR, McAuley BJ, et al. Angioplasty in total coronary artery occlusion:
experience in 76 consecutive patients. J Am Coll Cardiol 1985; 6:526–33.
17. Hochman Is, Lamas GA, Buller CE, et al. Coronary intervention for persistent occlusion
after myocardial infarction. N Engl J Med 2006; 355:2395–2407.
18. Dzavik V, Buller CE, Lamas GA, et al. Randomized trial of percutaneous coronary interven-
tions for subacute inarct related coronary occlusion to achieve long-term patency and
improve ventricular function: the Total Occlusion Study of Canada (TOSCA) – 2 trial.
Circulation 2006; 114:2449–2457.
19. Reifart N. Contralateral injections for chronic total occlusions using 4 F and the same groin.
In: Katoh O, Margolis J, Reifart N, Virmani R, eds. Chronic Total Occlusion Pathophysiology,
Intervention and Expert Case Management. Santa Clara, CA: Guidant Publications; 2001:
16–31.
20. Kiemeneij F, Laarman GJ, de Melker E. Transradial artery coronary angioplasty. Am Heart J
1995; 129:1–7.
21. Suttorp et al. for the PRISON II Investigators. Prospective Randomized Trial of Sirolimus-
Eluting and Bare Metal Stents in Patients With Chronic Total Occlusions (PRISON II). Results
presented at TCT 2005, Washington, DC.
22. Buller CE, Dzavik V, Carere RG, et al. Primary stenting versus balloon angioplasty in occluded
coronary arteries: the Total Occlusion Study of Canada (TOSCA). Circulation 1999;
100(3):236–42.
23. Stone GW, Colombo A, Teirstein PS, et al. Percutaneous recanalization of chronically occluded
coronary arteries: procedural techniques, devices, and results. Catheter Cardiovasc Interv
2005; 66:217–36.
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2
Guidewire techniques and
technologies: hydrophilic
versus stiff wire selection
Garrett B Wong, Matthew J Price, and Paul S Teirstein

Lesion characteristics ● Guidewire selection ● Conclusion

Chronic total occlusion (CTO) remains one of the most difficult challenges for the
interventional cardiologist. Both short- and long-term outcomes of patients with
CTOs are related to procedural success.1–6 Recent advancements in guidewire
technology have improved the technical success of approaching difficult CTOs,
such as occlusions that are calcified, long, and/or old. Success rates that were his-
torically 50–70%7,8 have now improved, for many interventionalists, to 80–90%.
Guidewires are available in a large variety of lengths, tip diameters and
shapes, coatings, stiffnesses, and materials. Guidewires can be classified into several
dichotomous categories: hydrophilic vs hydrophobic, stiff vs soft, supportive vs
non-supportive, and tapered vs non-tapered. This chapter focuses, on guidewire
technology and the appropriate selection of wires for different subsets of chronic
occlusions.

LESION CHARACTERISTICS
The overall success rate of opening CTOs depends on several lesion-specific
characteristics, which affects the selection of the appropriate guidewire. Known
predictors of success are:

● the duration that the vessel has been closed

● the length of the occlusion
● the presence or absence of antegrade flow
● the presence or absence of a stump
● the presence or absence of bridging collaterals.8–10

Collateralization of the distal vessel demonstrating a ‘target’ for guidewire pas-

sage can impact the success rate of crossing and ultimately recanalizing the
occluded vessel. There are multiple types of neovascularization, which may
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12 Handbook of Chronic Total Occlusions

develop in the setting of a highly stenosed lesion. Both ipsilateral and contralat-
eral collaterals may develop. Ipsilateral collaterals may be either epicardial
angiographic bridging collaterals or true microvascular collaterals. The particular
type of neovascular development often dictates the type of guidewire that is
used to cross the lesion.
Plaque composition is another important factor in the success or failure of CTO
revascularization. Histopathological evaluation of various lesions has allowed the
characterization of plaques, which can be roughly classified as ‘soft’, ‘hard’, or a
combination of both.11 Hard plaques are more prevalent in CTO lesions with
increasing age. A dense fibrotic lesion may not be crossed with a typical workhorse
wire and ultimately may require a stiffer guidewire to ‘push’ through the hard
plaque. In addition, calcification within the plaque adds a level of complexity
to the percutaneous coronary intervention (PCI) procedure. The fibrocalcific seg-
ments of the plaque are more likely to deflect the guidewire tip and lead to subin-
timal dissections and possibly perforations.

GUIDEWIRE SELECTION
Hydrophilic guidewires
Hydrophilic guidewires have special coatings engineered from absorbent materials,
which become slippery upon contact with liquids, such as saline or blood. There are
various polymeric coatings currently being utilized by the guidewire manufac-
turers to optimize wire performance and affect the degree of hydrophilicity. The
chemical properties of these polymeric coatings create a lubricious surface that
allows the guidewire to slide through tortuous segments and small channels easier
than a non-hydrophilic wire. The hydrophilic-coated guidewires are typically
useful in lesions which have visible channels that allow the wire to navigate
through the stenosed segment or segments. Additionally, these wires are superior
for markedly tortuous vessels and lesions, allowing the wire to glide through and
conform to the highly stenosed regions and around tight bends with more ease.
The wires are designed to offer little resistance when they contact the vessel wall
and soft tissue. The operator must therefore be cautious with the polymer-coated
wires as they can easily find there way into a false lumen with less tactile feed-
back, which, if not recognized, can lead to significant intimal dissection and pro-
cedural failure. In rare cases, this can cause coronary perforation and subsequent
cardiac tamponade.
There are a multitude of hydrophilic guidewires currently available, including
the Abbott Vascular (previously Guidant) Whisper and Hi-Torque Pilot series,
Asahi Intec Confianza Pro, Boston Scientific Choice PT and PT Graphix, Cordis
Shinobi and Shinobi Plus, and the Terumo Crosswire. The wires have a broad range
of torque response and lateral stiffness characteristics. In the setting of a chronic
occlusion, these slippery wires can be very useful in finding microchannels
through the difficult or tortuous lesion. In addition, once the lesion is successfully
crossed, the hydrophilic wires will easily track through the often small and under-
filled distal vessel with ease. Compared with non-hydrophilic wires, hydrophilic
wires excel in moving through occluded and calcified vessels but, as a class, are
generally less steerable than non-hydrophilic wires.
HCT_CH02.qxp 6/4/2007 6:37 PM Page 13

Guidewire technology: hydrophilic vs stiff wire 13

Hydrophilic guidewires have been compared with conventional wires in small

series of coronary intervention procedures. In a study by Lefèvre and colleagues,12
conventional non-coated wires were compared with the Terumo Crosswire for
difficult-to-cross lesions. When the hydrophilic Crosswire was used as the initial
guidewire, the success rate in crossing the lesion was 74% vs 35% for the conven-
tional wire (Table 2.1). When a conventional wire failed as the initial approach,
which occurred in 59% of the patients, more than a third of the lesions were suc-
cessfully traversed when crossed-over to the hydrophilic wire. In addition, a sig-
nificant decrease in number of guidewires used and the overall procedure time
were seen with the hydrophilic Crosswire.
Calcific or densely fibrotic lesions can be difficult to cross with the hydrophilic
coated guidewires. Several wires are available in different stiffnesses, such as the
Abbott Vascular Hi-Torque Pilot family, which includes wires with increasing
tip stiffness from the 50, to the 150, and up to the 200 (Figure 2.1). The increased
tip stiffness translates into more torque transmission and tip control (Figure 2.2).
All of these guidewires have a proprietary polymer coating to increase the
hydrophilicity. The stiffer, more powerful hydrophilic wires may allow the pen-
etration of the lesion cap, but this property may be disadvantageous in certain
lesion subsets. The calcified or thick fibrotic cap of certain total occlusions may
deflect the tip of these slick, stiff guidewires into a subintimal plane or through
the vessel wall, leading to a dissection or, rarely, to a perforation. Therefore, it is
important to emphasize the importance of visualization of the distal vessel via ipsi-
lateral or contralateral collaterals when using these wires. The use of multiple,
orthogonal views can be very useful to determine whether or not the distal wire
is truly in the proper vessel lumen. The lubricious coatings on these types of wires
can almost effortlessly allow the wires to continue to propagate extraluminally
alongside the true lumen once a false channel has been entered, especially with
the stiffer wires. Guidewire positioning should certainly be verified before any bal-
loon inflations are performed. A useful technique is to employ the Dotter method,13
simply passing a balloon catheter in and out through the lesion prior to any bal-
loon inflations, which can often discern whether or not the appropriate pathway
has been taken with the wire. If there is any evidence of extraluminal staining con-
sistent with a dissection, the wire can be withdrawn and redirected until the true
lumen is found. Distal balloon injection with contrast can also be useful to verify
wire position, but does not guarantee that the wire remains intraluminal for the
entire course, and in some cases the contrast injection may propagate the dissection
plane laterally and distally. Once the proper distal wire position is secured, the

Table 2.1 Conventional guidewire compared with the Terumo Crosswire

Parameter Conventional Crosswire p value

(n ⫽ 46) (n ⫽ 42)
First guidewire success (%) 35 74 0.001
Crossover (%) 59 26 0.009
Guidewire success after crossover (%) 37 0 ⬍0.001
Total guidewire number 1.7 ⫾ 0.6 1.3 ⫾ 0.5 ⬍0.001
Procedure (min) 84 ⫾ 33 42 ⫾ 20 0.013
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14 Handbook of Chronic Total Occlusions

Tip stiffness
9
8
7
6
Force (g)

5
4
3
2
1
0
ChoICE PT Graphix HT Pilot HT Pilot HT Pilot
PT INT 50 150 200

Figure 2.1 Comparison of guidewire tip stiffness.

Torque transmission
0.012
0.010
Torque (oz)

0.008
0.006
0.004
0.002
0
1 2 3 4 5 6 7 8
Number of rotations (¼ turns)

HT Pilot 50
HT Pilot 150
HT Pilot 200
PT Graphix INT
ChoICE PT

Figure 2.2 Comparison of guide wire torque transmission.

hydrophilic wire should be exchanged for a less traumatic and/or more supportive
wire to facilitate the angioplasty and stenting of the vessel and prevent distal dis-
section or perforation by the hydrophilic wire during stent manipulation.
Certain lesion subsets do not favor an initial hydrophilic guidewire approach.
A heavily fibrotic or calcific lesion cap may not be crossable with a polymer-coated
wire. Likewise, a flush occlusion at a side branch is highly unfavorable as the lubri-
cious guidewire will have a tendency to deflect off of the lesion and track into the
side branch. In these settings, the operator must exercise great care in wire man-
agement so as to not complicate the case any further with a wire dissection or per-
foration. These lesions typically will require the use of the stiffer, non-hydrophilic
group of wires.
HCT_CH02.qxp 6/4/2007 6:37 PM Page 15

Guidewire technology: hydrophilic vs stiff wire 15

One recently described technique using hydrophilic guidewires is to use their

lubricity to intentionally enter a false channel, form a J loop in the guidewire,
and use a support catheter to push the loop distally through the vessel wall until it
breaks through to the true lumen. This technique has been called the STAR (subin-
timal tracking and reentry) technique and has been more successful in chronic
right coronary occlusions which typically have the major side branches located
distally, as described in detail in Chapter 5.14
Another recently introduced approach is to take advantage of the collateral
circulation to perform a retrograde recanalization.15 Typically, septal collaterals are
used to pass from the right posterior descending artery (PDA) to the left anterior
descending artery (LAD) or from the LAD to the PDA. A hydrophilic guidewire
is used with a very low profile over-the-wire balloon catheter or hydrophilic-coated
support catheter. This technique is quite new and its success, failure, and compli-
cation rates have not yet been well defined; a dedicated chapter analyzes this
technical approach.

Stiff guidewires
Stiff guidewires make up the remainder of the coronary guidewires for approaching
CTOs. These wires have a standard, non-hydrophilic coil tip designed to facilitate
the penetration of either the proximal or distal cap, especially when the cap is
fibrotic and hard. In contrast to the typical workhorse wire with relatively floppy
tips and mild to moderate body support, these wires are designed to allow sufficient
transmission of steerability and crossing force at the target lesion.
The newest generation of more supportive, stiffer hydrophobic guidewires
includes the Asahi Intec Miraclebros series, and the tapered tip wires such as the
Asahi Intec Confianza and Abbott Vascular Hi-Torque Cross-It. These wires offer
superior torquability and tactile ‘feel’ for the lesions. The Asahi Intec guidewires
have a one-piece wire core that provides accurate 1:1 torque response, pushability,
and steerability. These wires vary in tip stiffness from the Miraclebros 3g (3 tip load),
4.5g, 6g , and up to the Miraclebros 12g. As the tip stiffness increases, the torque
transmission improves, with the tradeoff of less tip resistance transmission for the
operator. The Confianza series (also known as the Conquest outside the USA)
has a tapered tip from 0.014 inch down to 0.009 inch and carries either a 9g or 12g tip
load. The tapered segment provides greater penetration force and less tip resistance
than non-tapered wires. The Confianza Pro is a hybrid wire which has a hydrophilic
coating on all but its distal non-hydrophilic tip to allow improved torquability
and passage through fibrocalcific obstructions while minimizing the risk of entering
a false channel. The non-tapered Miraclebros family of wires offer better torque
performance and tactile feel, but less penetration force than the Confianza family.
The Abbott Vascular Hi-Torque Cross-It wires have a similar tapered tip from 0.014
inch to 0.010 inch over the last 3 cm, but these wires also have a hydrophilic coat-
ing over the tapered segment to allow smoother tracking and enhance the cross-
ing capabilities. This series of wires is available with increasing stiffness from the
Cross-It 100 to the Cross-It 200, 300, and 400 guidewires.
Tapered-tip guidewires have been shown to provide a significant benefit
in overall success rate of CTO PCI compared with conventional guidewires.16
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16 Handbook of Chronic Total Occlusions

In this retrospective study, 182 patients underwent PCI for CTO lesions of >3-month
duration. There were no significant differences in clinical or lesion characteristics
except for the use of tapered-tip guidewires. The overall success rate of PCI was
improved significantly with the use of tapered-tip guidewires, specifically in
tapered-type occlusions (p ⫽ 0.002) and shorter lengths of occlusion (p ⫽ 0.004).
These newer generations of stiff wires excel in the chronic occlusions that have
known unfavorable characteristics: thickened, fibrotic proximal and distal caps,
convex lesions with no distal tapering, relatively long lesions, and occlusions
that terminate at a significant side branch. These wires offer pushability through
the lesion with excellent tip control and torque response. Therefore, the operator
can steer away from the side branch or enter a lesion cap with the necessary control
to minimize complications. However, in a tortuous segment of the lesion, the wire
stiffness makes it more challenging to follow the true pathway beyond a sharp
turn, which can result in a subintimal dissection. The parallel wire technique can
be useful in this setting to attempt to cross through the lesion into the true distal
lumen. In this situation, the initial guidewire is left in the false channel when
reentry into the true lumen cannot be accomplished. A second guidewire, typically
with a different tip shape or stiffness, is then inserted alongside, or parallel, to the
initial wire. The goal is to advance the additional wire into the distal lumen beyond
the occlusion and to not continue reentering the subintimal space created by the first
wire. Our experience has demonstrated that a stiff, non-hydrophilic guidewire is
the preferred wire to optimize this technique.

Algorithm for guidewire selection

When approaching CTOs, the selection of the appropriate guidewire is critical to
the ultimate success or failure of the procedure. The operator must tailor the
particular wire to the specific lesion characteristics, as there is, unfortunately, not
a single wire that will be suitable for every CTO lesion subset. Wire exchanges
during the course of the procedure are common as the intervention progresses,
as the need for different wire characteristics dictates. Lesion chronicity, if known,
plays a role in the guidewire selection process. More recent occlusions are typically
less fibrotic than much older occlusions and may be crossed relatively easily without
the need for significant pushability.
An effective method of guidewire selection is to use a gradual step-up approach
(Figure 2.3). At our center, we will typically probe the lesion initially with a
standard workhorse wire (e.g. Abbott Vascular Balanced Middleweight or Asahi
Prowater) loaded in an over-the-wire balloon or other type of support catheter
to facilitate wire exchanges. Occasionally one is surprised by the ease of lesion
crossing. If there is any resistance at the lesion and there are no visible angio-
graphic microchannels conducive to the use of a hydrophilic wire, we routinely
exchange for our initial CTO guidewire, which is usually the Miraclebros 3 (MB3).
Guidewire shaping is an important factor, as a smaller curve on the wire tip is
favorable to a large curve to allow more coaxial force transmission at the lesion.
In harder, more fibrotic lesions, the MB3 may not offer the penetration force to
cross the lesion cap. A stepwise approach is to use the Miraclebros 4.5, then the
Miraclebros 6, and then ultimately advancing to the Miraclebros 12 or switching
to the Confianza series or Cross-It series. By gradually choosing stiffer wires with
HCT_CH02.qxp 6/4/2007 6:37 PM Page 17

Guidewire technology: hydrophilic vs stiff wire 17

Workhorse wire:

BMW Universal

Asahi Prowater

Miraclebros 3

Miraclebros 4.5

Miraclebros 6

Miraclebros 12

Confianza/Confianza Pro
Figure 2.3 Guidewire selection – step-up
Cross-It 200/400 approach.

higher tip loads, one can select the wire with the sufficient crossing force to suc-
cessfully penetrate the lesion (while minimizing the chance of vessel perforation
with an overly stiff wire) while maximizing the feel of the wire response. As the
tip stiffness increases, however, the tactile feel of the guidewires decreases. Once
the lesion has been successfully crossed, the stiff wire should be exchanged out
for a standard workhorse wire with a standard curve on the wire tip. Occasionally
a more supportive wire may be required to deliver the appropriate equipment
through the total occlusion.
An alternative approach is to again get an initial feel for the lesion with the
MB3 wire, but then move directly to a very stiff wire or a tapered tip wire if the
lesion appears to have a hard cap. This approach may be appropriate in very old
occlusions, which have a tendency to being more fibrotic, and possibly calcified.
The very stiff Miraclebros 12, the tapered tip Confianza wires, particularly the
Confianza Pro, Confianza Pro 12, and the Cross-It 200, 300, or 400, are the wires
of choice when in this situation. This is our preferred approach, in particular for
the lesion that is rather short with good distal collateralization but has a hard,
fibrous cap. In this situation, pushability and penetrability are the main require-
ments for success. The difficult CTO with the flush occlusion at a significant
side branch is also better suited for these stiffer, non-hydrophilic guidewires. A
hydrophilic guidewire in this situation will have a tendency to select the side
branch rather than penetrate the proximal lesion cap. The stiffer, non-coated wire
tips will minimize the deflection off of the hard lesion into the side branches.
During the course of a given PCI procedure of a CTO, the operator is often
faced with multiple complex decisions. For example, the initial portion of the lesion
may be quite tortuous and subtotally occluded for a significant length of vessel,
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18 Handbook of Chronic Total Occlusions

at which point the vessel becomes a total flush occlusion at the takeoff of a sizeable
side branch. This specific scenario may require multiple types of guidewires to
successfully negotiate the vessel. Again, an over-the-wire balloon catheter or
other support catheter will allow the operator to easily switch wires, depending
on the demands of the vessel segment. A hydrophilic steerable guidewire would
be the initial wire of choice for the tortuous, tiny channel to navigate through the
lengthy proximal segment. However, once the CTO at the takeoff of a side branch
is reached, a non-hydrophilic, stiff and powerful guidewire with a tapered tip may
be utilized to cross the fibrous cap of the true total occlusion, often in a stepwise
approach with progressively stiffer wires. It is important to know the strengths
and limitations of the various wires, and one should be careful not to attempt to
force a particular wire to open a CTO that may not be amenable to the characteris-
tics of that given wire. Occasionally, a given CTO may be ‘partially’ opened despite
the inability to completely access the distal true lumen. In such cases, recanaliza-
tion may be reattempted a few weeks later; the lesion may now demonstrate a
small channel, simplifying the procedure substantially.

CONCLUSION
Chronic total occlusions represent one of the most difficult procedural challenges
for interventional cardiologists. Previous lesion subsets that were once thought
to be untreatable by percutaneous intervention are now being successfully
opened as physician experience and guidewire innovations continue to improve.
An individualized lesion-based approach is necessary when treating chronic
coronary occlusions, because the anatomy of total occlusions varies. Proper knowl-
edge of the advantages and limitations of the different guidewires, in particular
the nuances between hydrophilic and stiffer guidewires, is essential to improving
the likelihood of procedural success. The operator should not hesitate to change
guidewires and strategies throughout the course of the intervention as the case
progresses in order to utilize the strengths of each wire. In the future, with
increasing experience and evolutionary advances in guidewire technology, the
final frontier of percutaneous revascularization – the chronic total occlusion – may
be conquered.

REFERENCE
1. Suero JA, Marso SP, Jones PG, et al. Procedural outcome and long term survival among
patients undergoing percutaneous coronary intervention of a chronic total occlusion in
native coronary arteries: a 20 year experience. J Am Coll Cardiol 2001; 38(2):409–14.
2. Choi SW, Lee CW, Hong MK, et al. Clinical and angiographic follow-up after long versus
short stenting in unselected chronic coronary occlusions. Clin Cardiol 2003; 26:265–8.
3. Rubartelli P, Verna E, Niccoli L, et al. Gruppo Italiano di Studio sullo Stent nelle Occlusioni
Coronariche Investigators. Coronary stent implantation is superior to balloon angioplasty
for chronic coronary occlusions: six-year clinical follow-up of the GISSOC trial. J Am Coll
Cardiol 2003; 41:1488–92.
4. Hoye A, Tanabe K, Lemos PA, et al. Significant reduction in restenosis after the use of
sirolimus-eluting stents in the treatment of chronic total occlusions. J Am Coll Cardiol 2004;
43:1954–8.
5. Werner GS, Krack A, Schwarz G, et al. Prevention of lesion recurrence in chronic total
occlusions by paclitaxel-eluting stents. J Am Coll Cardiol 2004; 44:23301–6.
HCT_CH02.qxp 6/4/2007 6:37 PM Page 19

Guidewire technology: hydrophilic vs stiff wire 19

6. Ge L, Iakovou I, Cosgrave J, et al. Immediate and mid-term outcomes of sirolimus-eluting

stent implantation for chronic total occlusions. Eur Heart J 2005; 26:1049–51.
7. Hoye A, van Domburg RT, Sonnenschein K, Serruys PW. Percutaneous coronary intervention
for chronic total occlusions: the thoraxcenter experience 1992–2002. Eur Heart J 2005; 26:
2630–6.
8. Stone GW, Rutherford BD, McConahay DR, et al. Procedural outcome of angioplasty for
total coronary artery occlusion: an analysis of 971 lesions in 905 patients. J Am Coll Cardiol
1990; 15:849–56.
9. Tan KH, Sulke N, Taub NA, et al. Determinants of success of coronary angioplasty in
patients with a chronic total occlusion: a multiple logistic regression model to improve
selection of patients. Br Heart 1993; 70:126–31.
10. Dong S, Smorgick Y, Nahir M, et al. Predictors for successful angioplasty of chronic totally
occluded coronary arteries. J Interv Cardiol 2005; 18:1–7.
11. Stone GW, Kandzari DE, Mehran R, et al. Percutaneous recanalization of chronically
occluded coronary arteries: a consensus document: part I. Circulation 2005; 112:2364–72.
12. Lefèvre T, Louvard Y, Loubeyre C, et al. A randomized study comparing two guidewire
strategies for angioplasty of chronic total coronary occlusion. Am J Cardiol 2000; 85:1144–7.
13. Dotter CT, Rosch J, Judkins MP. Transluminal dilatation of atherosclerotic stenosis. Surg
Gynecol Obstet 1968; 127:794–804.
14. Colombo A, Mikhail GW, Michev I, et al. Treating chronic total occlusions using subintimal
tracking and reentry: the STAR technique. Catheter Cardiovasc Interv 2005; 64:407–11.
15. Rosenmann D, Meerkin D, Almagor Y. Retrograde dilatation of chronic total occlusions via
collateral vessel in three patients. Catheter Cardiovasc Interv 2006; 67:250–3.
16. Saito S, Tanaka S, Hiroe Y, et al. Angioplasty for chronic total occlusion by using tapered-
tip guidewires. Catheter Cardiovasc Interv 2003; 59:305–11.
HCT_CH02.qxp 6/4/2007 6:37 PM Page 20
HCT_CH03.qxp 6/4/2007 6:38 PM Page 21

3
Advanced techniques for
antegrade advancement of wires
Etsuo Tsuchikane

Parallel wiring technique ● Seesaw wiring technique ● Anchoring balloon

technique ● IVUS guidance ● Conclusions

The antegrade advancement of wires through a chronic total occlusion (CTO) is

not only dependent on the type of wires used but also on the utilization of sev-
eral special techniques that can enhance procedural success. In order to be able to
take advantage of these techniques, the interventionist needs to understand their
technical details in a very organized fashion.

PARALLEL WIRING TECHNIQUE

This technique is the most important in the current wiring techniques for CTO.
Usually we start to tackle the CTO by single wire manipulation under fluo-
roscopy. However, sometimes this first wire slips into a subintimal space despite
careful wire handling. This is a common, usual situation in percutaneous coro-
nary intervention (PCI) of CTO. The important thing is to understand the ramifi-
cations of the next step. In these situations, operators tend to pull back and push
the same wire to seek the true channel. However, this procedure easily creates
expansion of the subintimal space, leading to true channel collapse, which in
turn makes it more difficult to recanalize the true lumen. Furthermore, to check
the position of the wire tip during single-wire manipulation, contrast media
injections are conducted frequently (both in fluoroscopy and in cineangiographic
modes), leading to increased radiation and contrast exposure. It is notable that
forceful antegrade injections also cause expansion of the subintimal space.
Therefore, once the first wire enters into the subintimal space, one may try to
get to the true channel by manipulating this wire’s course intentionally; how-
ever, this should be tried only a few times and one should never move this wire
any more unless those reattempts are successful.
The first wire should be left in place, and then a second wire should be deliv-
ered under the guidance (landmark) of the first wire, which usually indicates the
correct position of the true channel (Figure 3.1). The second wire should follow a
course according to the lessons learned from the first wire’s failure. The concept
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22 Handbook of Chronic Total Occlusions

Second wire
First wire Second wire position (a)
Second wire position (b)

Subintimal
Second wire position (a) space DX1
Subintimal space Second wire position (b)
LAD cranial view

First wire

Second wire

DX1 RAO view

First septal First septal

Figure 3.1 The concept of parallel wiring technique. This is a scheme of parallel wiring
technique in an LAD CTO (left anterior descending artery chronic total occlusion) case. The first
wire is slipping into the subintimal space in the pericardial side. To prevent the further expansion
of subintimal space, the first wire must be left there as an indicator for the second wire. The second
wire should be carefully advanced towards the distal end, so that it is positioned between (a) and
(b). Finally, the distal fibrous cap should be penetrated from this position by using a stiffer wire
than the first wire. RAO, right anterior oblique; DX1 first diagonal branch.

of parallel wiring technique also includes the saving of multiple antegrade con-
trast injections and avoidance of further expansion of subintimal space, since the
first wire serves as a landmark.
In order to change the wire course intentionally, the second wire usually has a
stiffer tip wire than the first wire. Depending on the lesion morphology, one may
use a tapered stiff wire such as the Confianza (Asahi Intec, Japan) in a short and
straight CTO to change the course and penetrate the distal fibrous cap (Figure 3.2).
Nonetheless, one should also consider a stiff wire with better torque perform-
ance such as the Miraclebros (Asahi Intec, Japan) family when trying to negotiate
a CTO in a tortuous vessel (Figure 3.3). Hydrophilic-coating stiff tip wires cannot
be recommended in the parallel wiring technique because they tend to slip into
the subintimal space.
Since a support catheter is required for wire handling in PCI of CTO, the oper-
ator has to retrieve the support catheter from the first wire and then deliver it
again with the second wire when using a small size of guiding catheter (6 Fr).
When using a big size of guiding catheter (7 or 8 Fr), a second support system can
be inserted for the second wire without retrieval of the initial support system. In
such cases, one can easily move on to the seesaw wiring technique, as mentioned
below. We usually use a big size of guiding catheter (8 Fr) in PCI of CTO so that
we can use any kind of wiring technique in addition to enhanced back-up force.
To have a greater chance of achieving successful recanalization, one should pre-
pare with all the favorable conditions from the beginning of the procedure;
accordingly, we usually employ an 8 Fr guiding catheter system.

SEESAW WIRING TECHNIQUE

The seesaw wiring technique, another type of parallel wiring technique, should
be called an ‘alternative parallel wiring’. This technique requires two support
HCT_CH03.qxp 6/4/2007 6:38 PM Page 23

Advanced techniques for antegrade advancement of wires 23

A C F

D
B G

Figure 3.2 Case example of an LAD CTO (left anterior descending artery chronic total
occlusion). A middle-aged male patient with bypass graft failure to the LAD area. The proximal
LAD was almost straight and the occlusion length was not so long (A, B). After the first wire
(Miraclebros 6) entered into the subintimal space (C), the second wire (Confianza) was easily
and successfully led into the distal true channel under the marker of the first wire (D, E). Final
angiographic result after stenting (F, G). In these cases with a short occlusion in the non-
tortuous vessel, a tapered stiff wire is easily controlled.

catheter systems. When the second wire also slips into the subintimal space in the
parallel wiring technique, it is used as a new indicator. Then the first wire should
be retrieved from the support catheter and another stiff wire (same as or stiffer
than the second wire) is delivered to negotiate the lesion. The operator can move
these two wire systems alternatively when necessary; this procedure is called the
‘seesaw wiring technique’. This technique has a high risk of worsening the
subintimal dilatation and may further compress the true lumen compared with
the basic ‘parallel wire’ technique. Therefore, routine use of this technique can-
not be recommended; if it is used, more careful wire handling is mandatory.

ANCHORING BALLOON TECHNIQUE

When the wire is unable to be advanced in the hard CTO lesion, the guiding
catheter and/or the support microcatheter necessarily gets pushed back during
wire handling. The unstable back-up condition prohibits appropriate wire manip-
ulation and may lead to complete equipment dislodgement from the target artery
in case it is not attended to properly. The anchoring balloon technique is an effec-
tive alternative for these situations. Two methods employ this technique.
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24 Handbook of Chronic Total Occlusions

A C D E

F G

Figure 3.3 Case example of an RCA CTO (right coronary artery chronic total occlusion). An
advanced-age female patient with post-infarction angina. Although the occlusion length was
not long, the RCA vessel was tortuous (A, B). The first wire, Miraclebros 3, delivered to
negotiate the occlusion slipped into the subintimal space (C). Then the second wire, Miraclebros
6, was carefully advanced using the parallel wiring technique (D) and a successful wire crossing
was achieved (E). Final angiographic result after stenting (F, G). In a CTO located in a tortuous
vessel, wires with high-torque performance should be used, particularly for the second wire in
the parallel wiring technique.

The first method aims to stabilize the guiding catheter and is useful in the
treatment of proximal CTO, particularly in right coronary cases (Figure 3.4). In
such situations, positioning and inflating a balloon in the conus branch or in an
acute marginal makes the guiding catheter stabilized, as an anchor. The size of
balloon should be matched to the size of the branch: a little bit bigger but inflated
at low pressure is the best combination in my experience. This procedure has a
risk of sinus bradycardia when the balloon is inflated in the conus branch. This
complication actually occurs rarely, and can be dealt with by conducting inter-
mittent inflations. Since two catheter systems are needed for this technique, an 8
Fr guiding catheter is again preferable.
The second method is to use an inflated over-the-wire (OTW) balloon during
wire handling. When a tight proximal fibrous cap cannot be penetrated, one can
enforce the back-up support by inserting and inflating a balloon over the work-
ing wire (Figure 3.5). In addition, the guiding catheter can be engaged deeply by
pulling on the inflated anchor balloon system. The size of the OTW balloon
should be matched to the reference lumen size proximal to the CTO. When a
long occluded CTO is attempted, a 1.5 OTW balloon can be used for this purpose
by inflating it inside the CTO. However, one should be careful not to dilate the
HCT_CH03.qxp 6/4/2007 6:38 PM Page 25

Advanced techniques for antegrade advancement of wires 25

A B C

D E

Figure 3.4 Case example of an RCA CTO (right coronary artery chronic total occlusion). A
middle-aged male patient with stable angina. The proximal RCA was completely blocked with
bridging collaterals (A). To prevent damage to the RCA ostium by the guiding catheter, a
Judkins-type catheter was used. However, because of the tight plaque in the CTO, the guiding
catheter was unstable during the wire handling so that the wire could not be advanced
intentionally (B). Then, a 2.5 mm balloon was inserted and inflated with a low pressure in the
conus branch to stabilize the guiding catheter (C). Under the use of this anchoring balloon, the
wire control was improved, so that the occlusion was successfully negotiated (D). Final
angiographic result after stenting (E).

Balloon

Figure 3.5 Another kind of anchoring balloon technique. This is a scheme of another type of
anchoring technique by using an over-the-wire (OTW) balloon. When the proximal fibrous cap
cannot be penetrated even by using a stiff wire, an OTW balloon may be dilated proximal to the
occlusion as a support catheter. The inflated balloon makes an extra back-up force for the wire
tip to break down the proximal cap.
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26 Handbook of Chronic Total Occlusions

false channel in the CTO. This technique may be particularly helpful for targeting
long CTO lesions that have several ‘islands;’ The 1.5 OTW balloon can be
dilated inside the first island with a certainty of being intraluminal, and proceeds
superior back-up support when manipulating the wire towards subsequent
‘islands’ through the CTO.

IVUS GUIDANCE
Intravascular ultrasound (IVUS) sometimes plays an important role for proce-
dural success of CTO, because it can provide us with the cross-sectional morphol-
ogy and size information that we cannot obtain with fluoroscopy. During wire
handling for CTO, IVUS could be effective for two settings: one is to confirm the
entrance of the CTO and the other to penetrate from the false to the true channel.
When there is no stump at the entrance of the CTO, an entry point may not be
located. In such cases, IVUS can locate the beginning of the CTO with certainty
(Figure 3.6). In a similar situation, even when we can easily identify the entrance,

A C

B F G

Figure 3.6 Case example of an LAD CTO (left anterior descending artery chronic total
occlusion). A middle-aged male patient with angina. Although the LAD was completely
blocked around the mid portion, it was hard to identify the entrance to the CTO, even when the
contralateral injection was performed (A, B). Then, an IVUS catheter was inserted into the
septal branch (C) so that the IVUS image easily indicated the CTO entrance (D, E). This
confirmation also facilitated the aggressive use of a stiff wire to penetrate the proximal cap (F).
Final angiographic result after stenting (G).
HCT_CH03.qxp 6/4/2007 6:39 PM Page 27

Advanced techniques for antegrade advancement of wires 27

it is sometimes important to check the entry point of the wire very early in the
procedure, because the wire may easily enter the subintimal space from the wrong
entry point in a CTO without stump. A case example is shown in Figure 3.7. It is
recommended that when you meet a CTO without a stump but a side branch big
enough to deliver an IVUS catheter, one should consider using IVUS to confirm
the entry point of the wire as well as the entrance of the occlusion when necessary.
In addition, when using a parallel wiring technique, the wires occasionally
enlarge the subintimal space in difficult CTO procedures. Once the subintimal
space expands beyond the distal end of the CTO, the distal true lumen can be
hardly seen in fluoroscopy. In these situations we often have to abandon the sub-
sequent procedure when only the angiographical guidance is used. However,
IVUS has a potential to make a breakthrough in these situations. If you deliver an
IVUS catheter through the wire in the subintimal space, the IVUS image clearly
shows important cross-sectional information: the IVUS catheter, a wire in the subin-
timal space, and a collapsed true channel. The next step is to introduce another
wire into the true channel under IVUS guidance. IVUS visualizes the direction of

A C D Second wire

First wire

IVUS
B

E F

Figure 3.7 Case example of an RCA CTO (right coronary artery chronic total occlusion). A
middle-aged female patient with angina. The first attempt at revascularization of the right
coronary CTO (A) failed. In the second attempt, the first wire (intermediate) easily went out of
the true channel (B). An intravasculor ultrasound (IVUS) image from the proximal small branch
(C) clearly showed that the entry point of the first wire was too close to the branch (D), so that
it easily advanced in the subintimal space. The correct position of the entry point for the second
wire is in the center of the obstructed true channel, directly opposite to the branch origin. So the
course of the next wire was intentionally changed from the CTO entrance towards the opposite
direction to the branch angiographically. This wire easily got into the distal small branch (E).
Final angiographic result after stenting (F). Such corrective action could be undertaken only by
IVUS guidance.
HCT_CH03.qxp 6/4/2007 6:39 PM Page 28

28 Handbook of Chronic Total Occlusions

the true channel and the entry point from the subintimal space into the true
lumen so that we can attempt to reach it with a stiff wire. A typical case is shown
in Figure 3.8.
On the other hand, some drawbacks and pitfalls in this procedure should be
mentioned:

1. To deliver an IVUS catheter through the subintimal space, a balloon dilata-

tion is sometimes required.
2. When a major perforation from the subintimal space is already observed,
never move on to this technique.
3. A big guiding catheter is needed to be able to deliver an IVUS catheter and
the support catheter/crossing wire system simultaneously.
4. To puncture the subintimal space, a sharp-cut stiff wire should be used, such
as a tapered stiff wire (Confianza, Asahi Intec, Japan).
5. Multiple stenting is mandatory after successful puncturing to fully cover the
extended subintimal space.

Finally, this procedure is not always successful. In our experience the success
rate is around 60%. The encouraging message is that we can retrieve more than

D F

A C
E

B G H

Figure 3.8 Case example of an RCA CTO (right coronary artery chronic total occlusion). An
elderly male patient with angina and an old myocardial infarction. The RCA had a very long
occlusion and was 3 years after occlusive instent restenosis (A). The parallel wiring technique
using stiff wires could not provide successful wire crossing (B). An IVUS catheter was advanced
through the wire in the false channel (C). The image clearly showed an expanded false lumen
and a collapsed true channel (D). The next step was to penetrate the true lumen from the false
channel by using a stiff wire. A Confianza wire made repeated attempts under IVUS guidance,
and finally this procedure was successful (E, F). Following this, the wire was carefully advanced
to the distal true channel (G). Final angiographic result after stenting is shown in panel H.
HCT_CH03.qxp 6/4/2007 6:39 PM Page 29

Advanced techniques for antegrade advancement of wires 29

half of angiographical failure cases by using IVUS. Thus, this technique could be
one of the last alternatives when standard wiring procedures fail.

CONCLUSIONS
Several specialized techniques can complement the classic single-wire manipula-
tion in a CTO. The parallel wire technique takes advantage of the lessons learned
during passage of the first wire into the subintimal space, and uses that wire as a
continuous landmark. A more aggressive alternative is the seesaw technique,
which includes alternating manipulations of two-wire systems within the subin-
timal space using each other as landmarks, but with a greater chance of com-
pressing the true channel than the parallel wire method. Anchoring of the guide,
using a balloon catheter, increases support. IVUS imaging can identify the CTO
entry when no stump is visible, and can help to locate the true channel when
inserted in the subintimal space.
HCT_CH03.qxp 6/4/2007 6:39 PM Page 30
HCT_CH04.qxp 6/4/2007 6:40 PM Page 31

4
Retrograde and bilateral
techniques
Jean-François Surmely and Osamu Katoh

Suitable channel for the retrograde approach ● Relevance of histopathology of CTOs

to the retrograde approach ● Description of retrograde technique ● Reaching the
distal end of the CTO with a retrograde wire ● Controlled Antegrade and Retrograde
subintimal Tracking (CART) technique ● Significance of septal collateral
dilatation ● Indications and limitations of the retrograde approach ● Conclusions

Percutaneous treatment of coronary total occlusions remains one of the major

challenges in interventional cardiology. Recent data have shown that successful
percutaneous recanalization of chronic total occlusions (CTOs) results in improved
survival, as well as enhanced left ventricular function, reduction in angina, and
improved exercise tolerance.1–3 However, because of the perceived procedural
complexity of angioplasty in CTOs, it still represents the most common reason
for referral to bypass surgery, or for choosing medical treatment.4,5 Over the past
few years, tremendous improvements in the PCI (percutaneous coronary inter-
vention) equipment and materials, as well as the growth of new treatment strate-
gies, have allowed us to tackle with success even complex CTO cases.
In this chapter on the retrograde approach for the percutaneous revasculariza-
tion of CTOs, we first give an overview of some basic knowledge about coronary
collateral channels, as well as the relevant histopathological features of CTOs,
before focusing on the description of the three techniques using a retrograde
approach.

SUITABLE CHANNEL FOR THE RETROGRADE APPROACH

The retrograde approach requires a channel between the occluded coronary
artery and another patent coronary artery, which enables the distal CTO site to
be reached in a retrograde way. The intercoronary channel can be either an epi-
cardial collateral, a septal collateral, or a bypass graft.

Anatomical classification of collaterals

In the human heart, the major epicardial coronary arteries and their branches
communicate with one another by means of anastomotic channels called collaterals.
HCT_CH04.qxp 6/4/2007 6:40 PM Page 32

32 Handbook of Chronic Total Occlusions

If stenosis of an epicardial coronary artery produces a pressure gradient across

such a channel, the collateral may become functional.
Our current knowledge on the anatomy and development of collaterals is
based upon autopsy studies6 or angiographic studies.7–9 Using plastic casts of
coronary arteries obtained in both normal and pathological human hearts,
Baroldi showed that in normal coronaries there are innumerable collaterals with
a diameter of 20–350 ␮m, and with a corkscrew aspect. The number of collaterals
and their diameter (up to a maximum of 1 mm) are increased in significant coro-
nary artery disease (CAD) (Figure 4.1). Baroldi proposed a classification based on
the relationship between the donor and recipient artery as follows:
● Homocoronary collaterals that connect segments of the same artery.
● between branches of the same artery, or within the same branch.
● Intercoronary collaterals that connect branches of different arteries.6
The limited resolution of angiography does not allow visualization of very small
collateral channels. In early studies, collaterals were seen angiographically only
when a severe narrowing (⬎90%) or a total occlusion was present.7,8 Based on
this careful analysis, Levin described 26 different collateral pathways. Based on a
recent angiographic assessment of collateral connection in patients with CTO
using an angiographic system with a 0.2 mm resolution, two further classifica-
tions have been proposed. The anatomical course of the principal collateral is
through septal connections (between septal perforators of anterior and posterior
descending arteries) in 44%, atrial epicardial connections in 32%, distal interarte-
rial connections in 18%, and bridging connections in 6%. According to the size of
the collaterals, there was no visible continuous connection between donor and
recipient artery in 14%, a continuous thread-like connection (⬍0.3 mm) in 51%,
and a continuous small side branch-like size of the collateral throughout its
course (⬎0.4 mm) in 35%.9

Figure 4.1 Coronary arteries plastic cast in a case of right coronary CTO. Left panel: numerous
homo- and intercoronary collaterals are seen on the anterior wall. Right panel: image showing
numerous continuous septal collaterals. (Courtesy of Dr Giorgio Baroldi.)
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