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98 PART IV Wires Technique
and sliding. The utility of these techniques is
determined by numerous factors such as CTO
lesion characteristics (anatomy of the proximal cap
and presence of calcification or microchannel) and
strategy being used.
The penetration technique is performed with stiffer
guidewires and is used for highly resistant CTO lesions
with blunt entry points, heavy calcification, or dense
fibrous tissue that were unable to be penetrated by less
aggressive wires. The guidewire tip is aimed at the
center of the lesion, which needs to be clearly identified
either using multiple angiographic projections with
bilateral contrast injections or using IVUS guidance. If
needed, the torque device can provide more precision
for the tip positioning. The penetration power is
dependent on guidewire tip stiffness, tip cross sectional
area, and lubricity of the guidewire coating, as well as
how much push/force the operator applies. The penetrating technique generally uses guidewires with a high
penetration power (such as the Confianza Pro and
Hornet series) and, therefore, has a higher risk of vessel
perforation. Small clock and counter-clock movements
can be made with the wire once the tip has engaged the
desired target to facilitate the wire penetration.
The drilling technique is best performed by
applying relatively quick 90–180 degrees clockwise
and counter-clockwise rotation of the guidewire with
modest forward motion. A shallow (30–45 degrees)
bend is generally performed at 1.0 mm from the distal
tip of the guidewire. The premise of this technique is
that the “drilling motion” of short tip of the guidewire
will decrease friction and allow the guidewire to
“find” the path of least resistance, usually the microchannels or the loosest part of the lesion.
The controlled-torquing technique is used for
intraplaque navigation during antegrade or retrograde wiring, using intermediate tip load very controllable guidewires with 1:1 torque response and
minimal whipping, such as the Gaia and the Judo
families (although some may also use the Confianza
Pro 9). This technique is usually reserved for short-tomoderate CTO segments where the vessel course is
well understood. In this technique, the goal is to
maintain the wire tip at the center of the plaque/
vessel. Low-to-moderate force is applied during
torquing, allowing the specialized wire to deflect hard
tissue and advance smoothly. The operator should use
two orthogonal angiographic views to create a mental
roadmap of the CTO. The guidewire tip should then
be rotated toward the target point using the shortest
distance to avoid a larger plaque disruption. This
technique has also been described as the 3 dimensional (3-D) wiring technique [5, 6] and utilizes a
spatial understanding of the location of the wire shaft
and tip within the vessel architecture (Figure 10.23).
The sliding technique is used to confirm the
guidewire position in the true lumen. After
crossing the distal cap of the CTO or re-entering
into the true lumen, the operator needs to confirm
the position of the guidewire. The most common
way is to inject retrogradely and visualize the true
lumen position. Occasionally, opacification is not
good, or the injection cannot be done (ipsi-lateral
collaterals with high risk of dissection propagation). In these cases, the operator can simply slide
the guidewire down the vessel by applying a gentle
push with no rotation. If the wire buckles, it is
likely not in the true lumen. If it goes smoothly
down the natural course of the vessel, it is likely in
the true lumen. Ideally, one should still confirm
the guidewire position before advancing anything
else (such as a microcatheter) to avoid higher
grade coronary perforation. Once the guidewire
reaches the distal segment of the vessel, opacification may be better, allowing the confirmation.
Another way to check is to direct the guidewire
into side branches. Although not conclusive,
repeatedly entering side branches is a valid
alternative to confirm intra luminal position.
Guidewire escalation and de-escalation
The general principle in CTO PCI guidewire selection
is to have logical, stepwise approach with gradual
escalation and de-escalation according to what needs
to be accomplished (Figure 10.24). It is not unreasonable to give a brief attempt in most antegrade
approaches with a soft tip, polymeric guidewire to
access any potential microchannels. However, the
operator should be facile at identifying when a
strategy is not working and rapidly transition and
change tactics if needed. Once the specific task has
been accomplished (proximal cap penetration, for instance), the operator needs to re-assess what is the
next objective (intra-plaque crossing, for instance)
and decide what is the best and safest guidewire to
achieve that.
Conclusion
Significant advances in guidewire technology have
improved CTO PCI success rates and there is currently a plethora of options available for clinical use. It
is imperative that CTO operators curate a subset of
these guidewires for their toolkit and become familiar
with the construction, characteristics, case use and
technical handling of these wires.
CHAPTER 10 CTO Wires: Engineering 101 and Principles of Wire Manipulation 99
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Figure 10.23 Eight conceptual locations of wire shaft (a) and
wire tip directions (b) in subintimal plane at distal cap. Table
showing location and directions of wire shaft and tip,
respectively, in 2 orthogonal views and the derived true shaft
locations or tip directions in 3D space (c).3D=3dimensional;
A = true anterior; L = true left; LA = left and anterior; LAO =
left anterior oblique; LP = left and posterior; P = true
posterior; R = true right; RA = right and anterior; RAO ¼
right anterior oblique; RP ¼ right and posterior. Image and
caption reproduced with permission from [6].
Figure 10.24 Guidewire escalation and de-escalation.
100 PART IV Wires Technique
References
1 Sapontis J, Christopoulos G, Grantham JA, Wyman RM,
Alaswad K, Karmpaliotis D et al. Procedural failure of
chronic total occlusion percutaneous coronary intervention: insights from a multicenter US registry. Catheter
Cardiovasc Interv Off J Soc Card Angiogr Interv 2015 Jun;
85(7): 1115–1122.
2 PTCA guide wires [Internet]. Vascular perspectives.
[accessed 2022 August 9th]. Available from: https://www.
vascularper spectives.com/cardiology/ptca-guide-wires.
3 Katsuragawa M, Fujiwara H, Miyamae M, Sasayama S.
Histologic studies in percutaneous transluminal coronary
angioplasty for chronic total occlusion: comparison of
tapering and abrupt types of occlusion and short and long
occluded segments. J Am Coll Cardiol 1993 Mar 1; 21(3):
604–611.
4 Ybarra LF, Rinfret S, Brilakis ES, Karmpaliotis D, Azzalini
L, Grantham JA et al. Definitions and clinical trial design
principles for coronary artery chronic total occlusion
therapies: CTO-ARC consensus recommendations.
Circulation 2021 Feb 2; 143(5): 479–500.
5 Okamura A, Iwakura K, Nagai H, Kawamura K, Yamasaki
T, Fujii K. Chronic total occlusion treated with coronary
intervention by three-dimensional guidewire manipula-
tion: an experimental study and clinical experience.
Cardiovasc Interv Ther 2016 Jul; 31(3): 238–244.
6 Goel PK, Sahu AK. 3D Wiring in CTO intervention:
cracking the code. JACC Cardiovasc Interv 2021 Apr 12;
14(7): 803–806.
11
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CHAPTER 11
Use of Two Wires in the Treatment
of CTO
Thierry Lefèvre* & Thomas Hovasse
Institut Cardiovasculaire Paris Sud (ICPS), Massy, France
* Corresponding author
The success rate and the safety of chronic total occlusion (CTO) revascularization has greatly improved in
the last two decades thanks to the development of new
dedicated guidewires, microcatheters, and new techniques and shared experience with expert operators.
These advancements are also attributable to enhanced
anatomical and histological understanding of CTO
lesions, increasing operator experience and experience sharing with expert operators and last but not
least, “mental power” which is required for these complex procedures.
In order to increase the success rate of CTO-PCI, it
is important to take time to carefully review the cinefilm in order to have a complete anatomical understanding of the CTO and accurate visualization of the
entry and exit point of the occluded site, the severity
of potential tortuosities in or proximal to the occluded
site, presence, and location of calcifications which
may influence selection of GW, length of the lesion,
presence of important side-branches (SB) which
should be protected, presence of bridging collaterals
which may overlap the occluded site, and size of the
distal run-off which is a well-known predictor of
failure [1–4].
The use of two or more angioplasty guidewires is
common in this setting and deserves thorough
discussion as it could be a key to success.
Use of a second wire to improve
guiding catheter safety, stability,
and power
When the guiding catheter is unstable, a first workhorse PCI wire can be positioned in a proximal SB in
order to stabilize the guiding catheter [5, 6] and allow
the crossing of the occlusion with a dedicated microcatheter and wire (Figure 11.1).
For the contralateral injection, parking a workhorse
wire in the guiding catheter improve not only the stability of the guide all along the procedure, but also the
safety by decreasing the risk of dissection during
injection and it is strongly recommended.
Use of a second wire for side-branch
protection
The presence of a bifurcation in the proximal, distal
part or body of the CTO is frequent, about 1/3 of cases
(Figure 11.2). Such branches should be protected with
a wire as soon as possible, before predilatation and at
least before stent deployment in order to avoid incomplete recanalization due to the loss of a significant SB.
A double-lumen microcatheter can be very useful
in this setting in order to decrease the risk of hematoma when trying to access the SB which may also
increase the risk of losing the SB.
Need for different types of wire for
crossing the lesion
Tissue hardness along the occlusion, from entry to
exit point, is extremely variable [7]. It is often helpful
to use various types of wire to cross the occlusion.
Soft wires such as fielder XT have been associated in
the past with a procedural success increase in our institution [8]. These guidewires are able to penetrate and
run along invisible microchannels inside the occlusion. They should have a short distal shape, especially
when used in small occluded vessels. In many cases, it
is necessary to engage the occluded segment with a
Chronic Total Occlusions: A Guide to Recanalization, Third Edition. Edited by Ron Waksman and Shigeru Saito.
© 2024 John Wiley & Sons Ltd. Published 2024 by John Wiley & Sons Ltd.
101
102 PART IV Wires Technique
(a)
(b)
(c)
(a) (b) (c)
Figure 11.1 Example of the anchoring wire technique. Guiding-catheter instability with inability to cross the lesion.
Successful wiring using a soft CTO wire, after inserting a workhorse wire in the proximal SB (white arrow).
(d)
(e)
Figure 11.2 Use of a second wire in a CTO with bifurcation lesion. (a): CTO of the mid LAD. (b): Successful wiring and
pre-dilatation using a soft wire and 2 mm balloon. (c): Workhorse wire inserted in the diagonal branch. (d): Kissing
balloon inflation performed after main branch stenting and Proximal Optimization Technique. (e): Final result.
CHAPTER 11 Use of Two Wires in the Treatment of CTO 103
(a) (b) (c) (d)
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microcatheter mounted on an ordinary wire. Though
the presence of calcifications is a predictor of guidewire failure, these guidewires have shown their ability
to traverse sometimes very calcified lesions.
However, as the proximal cap of the occlusion is
submitted to systemic pressure, it is harder to penetrate than the distal cap, which receives collateral
pressure, and the body of the occlusion. It is, therefore, sometimes necessary to penetrate the proximal
cap with a stiffer wire (escalation) and then exchanged
on the micro-catheter [9] for a softer wire (de-escalation) in order to progress more distally without creating dissections or hematoma.
Two wires or more for parallel wire
technique
The parallel wire technique was developed in the last
century, nearly disappeared in many centers with the
development of dissection-reentry techniques, and came
back more recently with the creation of new highly controllable wires. It is a very important technique, which
increase the success rate of antegrade CTO PCI even in
difficult cases and long lesions. It is difficult to differentiate between a false and a true lumen at the occluded site
and from a technical point of view, re-entering the distal
site from a false lumen is relatively difficult and increase
the risk of losing the SB. When the wire is in a false
lumen it is preferable to leave it there and use a second
wire with a different distal shape and/or a different stiffness in order to find the true lumen. The first wire serves
as marker to advance the second one in the true lumen.
In some instances, it may be helpful to use three wires
(Figure 11.3). This parallel wire technique can be carried
out with the support of one or two microcatheters (seesaw technique), double lumen microcatheters or the
Recross microcatheter [9]. This, which generally requires
the use of a 7- or 8-Fr guiding catheter.
Side branch techniques
When the wire is not moving intraplaque, before creating a hematoma or a false lumen, the use of a second
wire to reach a SB in the CTO body may prove very helpful. The result of this maneuver should be assessed
through a contralateral injection or by IVUS in order to
ensure that the wire is in the SB true lumen (Figure 11.4).
Then it can be very useful to dilate using a balloon sized
to the SB with a small balloon, leave the wire in the SB,
and then use this branch as an island inside the CTO
body. A second wire can be used as a parallel wire to
advance in the main branch through the occlusion step
by step toward another distal SB or the distal bed. Double
lumen micro-catheters are very useful to manage the two
wires. The risk in over dilating the proximal segment
toward a SB is the possibility of creating a “shortcut,” with
occlusion of the distal bed of the vessel [10, 11].
After insertion of the wire into the SB, distal penetration of the second wire in the main branch is facilitated by orienting the wire toward the carina of the
bifurcation (where there is less disease, progression of
the atheroma being opposite to the carina). Proximal
optimization technique using a balloon proximal to
the carina can also be very useful [12].
IVUS guidance
When localization of the occlusion at the proximal
cap or re-entry point proves impossible, a second wire
may be used for IVUS guided visualization [13, 14]
purposes in order to redirect a second the wire into
the true lumen. This technique may prove useful in
cases where the occluded segment is immediately
distal to a patent SB which can accommodate an IVUS
catheter. The IVUS catheter is positioned opposite to
the occlusion while a CTO wire is used to penetrate
the proximal cap.
Figure 11.3 Example of parallel wire technique. (a): CTO of the mid LAD in a patient with LIMA occlusion. (b): False
lumen with the Miracle 4.5 wire (white arrow), a Miracle 6 wire is used to find the true lumen. (c): Successful crossing
with the Miracle 6. (d): Final result.
104 PART IV Wires Technique
(a) (b)
(c)
(d) (e)
Figure 11.4 (a): Chronic occlusion of the right coronary artery. Double injection. Miracle 6 guidewire in the false lumen.
(b): Contralateral injection allowing visualization of the route of the second wire (ASAHI medium) which is positioned in
a side branch (c): Selective injection (d): Second wire positioned in the main branch. (e): Final result.
The use of a 7 or 8-Fr guiding catheter is necessary
when penetration of the occlusion is performed under
IVUS guidance using a wire supported by a microcatheter. IVUS may confirm the adequate positioning
of the wire adjacent to the origin of the CTO, but it
does not provide any guidance for distal crossing.
Wire re-entry can also be IVUS-guided, with the
IVUS catheter being pushed toward a dissected segment whilst using a second wire to localize the true
lumen, either a soft wire in the presence of an anterograde flow, or a stiff, tapered wire in order to penetrate
the true lumen from the false one. In such a case,
IVUS guidance serves to confirm the positioning of
the wire in a false lumen and visualize the true lumen.
IVUS may also be used in a SB branch proximal to the
CTO (IVUS guided penetration), in order to guide
the progression of a second wire in the main branch
(Figure 11.5).
Wires and retrograde approach
The retrograde access is always bilateral [15–20]. The
wire inserted via a retrograde approach may reach the
distal bed of the occluded artery through septal collateral vessels, through epicardial collateral vessels, or
sometimes through collateral vessels in the left
atrioventricular groove or via atrial branches.
The use of a microcatheter or a channel dilator in
collateral septal vessels obviates the need for predilatation of the septal arteries in most instances. An ordinary wire should be used in order to position a
microcatheter at the entrance to the collateral channel
and allow angiographic assessment of the pathway,
with subsequent exchange for a dedicated wire.
Retrograde advancement of a guide wire in the distal
bed of the occluded vessel has multiple advantages:
•
The wire may serve as a marker of the distal end of
the CTO to facilitate anterograde wire insertion
(marker wire technique).
•
It may facilitate the positioning of a microcatheter
next to the distal end of the CTO in order to allow
micro-angiographic guidance with very small volumes of contrast medium (Figure 11.6).
•
The wire may be advanced into the occlusion to
meet the anterograde wire (touching wire).
•
It may be used to position a balloon subsequently
inflated inside the distal segment of the occlusion in
order to create sufficient space to accommodate the
anterograde wire (CART technique).
•
It may be advanced along the whole occluded segment by creating a loop (knuckle technique) using a
soft hydrophilic wire or by inflating a balloon on
the anterograde wire in the proximal segment of the
occlusion (reverse CART technique).
CHAPTER 11 Use of Two Wires in the Treatment of CTO 105
(a)
(b)
(c)
(a)
(b) (c)
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Collateral
(d) (e)
Figure 11.5 Old occlusion of the proximal RCA with inferior viability and ischemia. (a): Mid RCA occlusion (double arrows)
without defined take-off (7 Fr AL2 guiding catheter). (b): IVUS catheter, microcatheter, and soft and tapered wire penetrating
the occlusion. (c): IVUS guidance of wire penetration. (d): Soft wire in the distal part of the occlusion. (e): Final result.
Figure 11.6 Mid LAD occlusion. (a): Distal filling through a septal-septal connection. (b): “Micro” guidance with a
microcatheter inserted into the first septal branch (arrow = distal marker). (c): Final result.
•
When the retrograde wire crosses the occlusion
successfully (Figure 11.7), it may be advanced in the
anterograde guiding catheter where it can be jailed
by inflating a balloon compatible with the guiding
catheter diameter.
•
The guide used for retrograde crossing of the occlusion may be inserted into the anterograde guiding
catheter with subsequent advancement of the
microcatheter, before being exchanged for a dedicated wire for externalization through the Y connector of the anterograde guiding catheter.
•
In cases where insertion of the retrograde wire into
the anterograde catheter proves impossible, it may
be captured by means of a snare when coming out
of the aorta or in a subclavian artery when the
procedure is carried out via the radial approach.
106 PART IV Wires Technique
(a)
(b)
(c)
(d)
(e) (f)
Figure 11.7 (a): Chronic occlusion of the right coronary artery. False lumen created during a previous attempt carried out
4 weeks before. (b): Failure wire ibn the true lumen using parallel wire technique. (c): Retrograde approach with easy
crossing of the distal part of the occlusion. (d): Retrograde sub selective injection using a microcatheter in order to
ensure appropriate positioning. (e, f, g): Retrograde dilation, antegrade wiring with a workhorse wire, final result.
Buddy wire technique
This technique has been widely described and consists of
inserting a second wire (or more) into the reopened vessel
in order to facilitate the passage of a stent in complex
lesions. It may prove very helpful in CTO for advancing a
balloon downward, especially in stent CTOs (Figure 11.8).
Today extension catheters are very helpful [15–20] to solve
this issue by increasing the support of the guiding catheter
and facilitating stent delivery.
Anchoring stent technique
This is a more sophisticated “anchoring technique”
used when distal crossing with balloon or stent proves
impossible, which consists of “jailing” a second wire
outside the proximal stent for distal balloon/stent
advancement. This can be sometimes anticipated in
case of CTO bifurcation by leaving the SB wire after
the first stent delivery. The jailed wire should be
removed before deployment of the second stent in
(g)
order to avoid trapping the wire with two stents,
Anchoring balloon technique
When the balloon catheter cannot be advanced
which increase the risk of wire fracture. As described
above this technique has become rare thanks to guiding extension catheter which provide strong support.
through the lesion after wire crossing, it may be helpful to insert a second wire into a proximal branch in
order to inflate a balloon to anchor the guiding catheter. This may facilitate wire or balloon passage across
the occlusion (Figure 11.9) This technique may also
be used to advance the stent toward the lesion in complex instances. Today this technique is less used
thanks to the development of guiding catheter
extensions.
Conclusion
One of the keys to successful treatment of chronic
total occlusion lies in the correct mastering of the
multiwire strategy. This approach consists of inserting
one or several wires in order to stabilize, increase the
support and improve the safety of the guiding-catheters, accommodate varying degrees of tissue hardness
CHAPTER 11 Use of Two Wires in the Treatment of CTO 107
(a)
(b)
(c)
(d)
(a)
(b) (c)
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(e) (f)
Figure 11.8 Example of side-branch protection and buddy wire technique. (a): Chronic total occlusion of the mid LAD at
the level of previous stent implantation, just distal to the bifurcation with the first diagonal branch. (b): Successful wiring.
(c): Inability to cross the lesion with a microcatheter and a dedicated small balloon despite anchoring balloon technique
(white arrow). (d): buddy wire technique to help crossing the CTO distal cap by using a more distal diagonal branch (white
arrow). (e): Kissing balloon inflation after main branch stenting and Proximal Optimization Technique. (f) Final result.
Figure 11.9 Example of anchoring balloon technique. (a): CTO of the right coronary artery. (b), (c), (d): Anchoring balloon
in a side-branch (white arrow) and progression of the dedicated small balloon into the CTO. (e): Final result after stenting.
(d) (e)
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