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108 PART IV Wires Technique
and tortuosities, “mark” dissections, facilitate parallel
wire technique and protect significant side-branches.
Implementation of this technique requires a thorough acquaintance with the specific features of the
numerous wires, microcatheters that may be used in
CTO as well as the original techniques which have
been developed in this setting.
References
1 Di Mario C, Werner GS, Sianos G et al. European per-
spective in the recanalisation of Chronic Total Occlusions
(CTO): consensus document from the EuroCTO club.
EuroInterv 2007; 3: 30–43.
2 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: 217–236.
3 Kinoshita I, Katoh O, Nariyama J et al. Coronary
angioplasty of chronic total occlusions with bridging collateral vessels: immediate and follow-up outcome from a
large single-center experience. J Am Coll Cardiol 1995;
26: 409–415.
4 Noguchi T, Miyazaki MDS, Morii I et al. Percutaneous
transluminal coronary angioplasty of chronic total occlusions: determinants of primary success and long-term
outcome. Cathet Cardiovasc Intervent 2000; 49: 258–264.
5 Hirokami M, Saito S, Muto H. Anchoring technique to
improve guiding catheter support in coronary angioplasty
of chronic total occlusions. Catheter Cardiovasc Interv
2006 Mar; 67: 366–371.
6 Hamood H, Makhoul N, Grenadir E et al. Anchor wire
technique improves device deliverability during PCI of
CTOs and other complex subsets. Acute Card Care 2006;
8: 139–142.
7 Suzuki T, Hosokawa H, Yokoya K et al. Time-dependent
morphologic characteristics in angiographic chronic
total coronary occlusions. Am J Cardiol 2001; 88:
167–169.
8 Hayashida K, Louvard Y, Khand A et al. Risk factors for
procedural failure of percutaneous coronary intervention for chronic total occlusion. Impact of novel guide
wire “Fielder XT”. Achives of c ardiovascular diseases sup-
plement 2011;3:24.
9 Pyxaras SA, Galassi AR, Werner GS et al. Dual lumen
microcatheters for recanalisation of chronic total occlu-
sions: a EuroCTO club expert panel report. EuroIntervention
2021; 17(12): e966–e970.
10 Azzalini L, Moroni F, Santiago R. Subintimal shift at the
bifurcation: a cause of side branch occlusion in chronic
total occlusion intervention. Cardiovasc Revasc Med
2021 Jun 27:S1553-8389(21)00489-9. doi: 10.1016/j.carrev.2021.06.124. Epub ahead of print. PMID: 34215558.
11 Gutiérrez-Chico JL, Cortés C, Ayoub M.et alSubintimal
shift as mechanism for side-branch occlusion in percutaneous treatment of chronic total occlusions with bifurcation lesions. Cardiol J 2021 Aug 12. doi: 10.5603/CJ.
a2021.0079. Epub ahead of print. PMID: 34231874.
12 Yokoi K, Sonoda S, Yoshioka G et al Proximal optimiza-
tion technique facilitates wire entry into stumpless
chronic total occlusion of side branch. JACC Cardiovasc
Intrv 2021; 14 (17): e231–e233.
13 Fujii K, Ochiai M, Mintz GS et al. Procedural implica-
tions of intravascular ultrasound morphologic features of
chronic total coronary occlusions. Am J Cardiol 2006; 97:
1455–1462.
14 Galassi AR, Sumitsuji S, Boukhris M et al. Utility of intra-
vascular ultrasound in percutaneous revascularization of
chronic total occlusions. JACC Cardiovasc Interv 2016;
9(19): 1979–1991.
15 Surmely JF, Tsuchikane E, Katoh O et al. New concept for
CTO recanalization using controlled antegrade and retrograde subintimal tracking: the CART technique. J
Invasive Cardiol 2006; 18: 334–338.
16 Surmely JF, Katoh O, Tsuchikane E et al. Coronary septal
collaterals as an access for the retrograde approach in the
percutaneous treatment of coronary chronic total occlusions. Catheter Cardiovasc Interv 2007; 69: 826–832.
17 Matsumi J, Saito S. Progress in the retrograde approach
for chronic total coronary artery occlusion: a case with
successful angioplasty using CART and reverse-anchoring techniques 3 years after failed PCI via a retrograde
approach. Catheter Cardiovasc Interv 2008; 71: 810–814.
18 Saito S. Different strategies of retrograde approach in
coronary angioplasty for chronic total occlusion. Catheter
Cardiovasc Interv 2008; 71: 8–19.
19 Galassi AR, Werner GS, Boukhris M et al . Percutaneous
recanalisation of chronic total occlusions: 2019 consensus
document from the EuroCTO club. EuroIntervention
2019; 15: 198–208.
20 Wu EB, Brilakis ES, Mashayekhi K et al. Global chronic
total occlusion crossing algorithm: JACC state-of-the-art
review. J Am Coll Cardiol 2021; 78: 840–853.
12
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CHAPTER 12
Parallel-Wire Techniques
Sudhir Rathore1,* & Takahiko Suzuki
1
Frimley Health NHS Foundation Trust, Surrey, UK
2
Toyohashi Heart Centre, Toyohashi, Japan
* Corresponding author
Introduction
Percutaneous coronary intervention (PCI) of chronic
total occlusion (CTO) is considered as the major frontier in interventional cardiology. Procedural success
rate for CTO has improved over time but is still low in
contemporary practice and is mainly due to the failure
to cross the lesion with the guide wire [1–6]. Antegrade
wire escalation (AWE) remains the main approach in
majority of the cases and with a single wire, a success
rate of between 50% and 70% can be achieved [5, 6].
Recent development of dedicated guide wires and
hardware, newer techniques (antegrade dissection reentry (ADR) and Retrograde approaches), increasing
clinical experience and skills has improved the procedural outcomes with CTO PCI [7–12]
In the standard AWE approach with a single wire, a
conventional coiled floppy-tipped guidewire, hydrophilic floppy-tipped guidewire and or polymer jacket
soft tapered wires are used for the initial interrogation of
CTO lesions to find the true lumen. If this strategy is not
successful, wires with stepwise increased stiffness and
tapered wires with hydrophilic coating are then chosen.
After penetration of the proximal CTO fibrous cap,
the guidewire often enters the subintima, creating a
subintimal lumen. Repeated wire manipulations to
redirect the guidewire into the CTO body can result in
extensive subintimal dissection with accompanying
extramural hematoma. Such dissections extend circumferentially and longitudinally and can compress
the distal true lumen, which makes at times distal true
lumen re-entry difficult [4, 13]. Another common
reason for unsuccessful recanalization is the difficulty
to perforate the CTO distal fibrous cap, the guidewire
sliding consequently in the subintimal space. Entry of
Antegrade wire in the subintimal space is the common scenario and often leads to the procedure failure
or switching to ADR and or Retrograde approaches,
2
which requires expert skill sets, excess procedure
time, and may result in higher complications.
The difficulty to redirect a wire into a CTO segment
until it passes to the distal vessel true lumen, as well as
the increased complications risks associated to repeated
guidewire manipulations in the subintimal space, has
led to the development and refinement of the parallelwire technique. Several studies have shown increased
success rates of CTO recanalization with the use of parallel wire techniques in contemporary practice [14–19].
Parallel-wire technique
The parallel-wire technique has two main purposes:
redirecting a wire inside the body of the CTO, and
puncture of the distal CTO fibrous cap. An important
pre-requisite for using the parallel-wire technique is the
visualization of the distal true lumen, filled via collaterals, on angiography. Indeed, the visualization of the first
guidewire and its relative position to the distal true
lumen, as well as its relative position to the second
guidewire, using orthogonal angiographic views, is necessary for the success of this technique. A contralateral
injection is needed for the visualization of the distal true
lumen, apart from cases with ipsilateral collaterals. It is
important to switch to the parallel wire technique before
a large subintimal dissection occurs, as the chance of
successful recanalization by the second guidewire
decreases proportionally to the severity of the subintimal dissection induced by the first guidewire.
Technique description
When a wire has entered a false channel or
sub-intimal space, it is left in place in the dissection
plane as a marker, and a second guidewire is passed
along the same path parallel to the first wire to enter
distal true lumen (Figure 12.1). The main pitfall of
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.
109
110 PART IV Wires Technique
First wire
Second wire
Figure 12.1 Schematic demonstration of parallel wire
technique. If the first guide wire goes to sub-intimal space,
and creates a false lumen in the CTO, leaving the wire in
the false lumen and introducing a new stiffer wire into
the true lumen is often effective as shown here.
this technique is the occurrence of the two wires
twisting with each other. To avoid wires twisting,
usage of a support micro catheter and appropriate
wires selection/handling are necessary.
(A)
Miracle 3g
(B) (C)(D)
Use and correct positioning of a support catheter: We
can either use an over-the-wire balloon catheter, or a
microcatheter. It is important to advance the tip of
the support catheter just in front of the proximal
CTO cap. We favor the use of the Transit® (Jonhson &
Jonhson), Finecross® (Terumo) or Corsair (Asahi)
micro-catheter, as their tips are very flexible, which
allows a better wire maneuverability. The use of the
support catheter also allows maintaining an acceptable maneuverability of the second wire as well as enables the reshaping of the wire tip easily without losing
position.
Wires selection and handling: The second wire is
advanced inside the CTO to closely follow the course
of the first wire, “hugging” it as it goes. The important thing is identifying the exact relative positions
of the two wire tips. The second wire is moved in the
direction of the true lumen as assessed by orthogonal views, and in relation to the first wire. Be careful
while the wires do not get too tangled up with each
Miracle 6g
Parallel wire
LAO view
(E)
RAO view
Figure 12.2 Example illustrating the use of the parallelwire technique in Right Coronary short CTO lesion.
Contrast injection allows visualizing the distal CTO end,
and to imagine the course of the occlusion on the baseline
angiography (panel A). A first wire could cross the CTO
body but was not able to penetrate the CTO distal fibrous
cap, sliding at this point into the subintimal space (panels
B and C). Parallel-wire technique was thereafter
undertaken using stiffer wire and sharp bend at the tip to
control direction. A second wire (Miracle 12 g) with a
different tip curve was brought along the same path up to
the distal fibrous cap closely guiding the tip of the wire
towards distal true lumen in orthogonal views using first
wire as a guide (panel D). The second wire could enter the
distal true lumen of the RCA. Final result after stent
implantation is shown in panel E.
1st wire
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(shooting XT)
2nd wire
(Miracle 12 g)
CHAPTER 12 Parallel-Wire Techniques 111
(A)
(B)
1st wire (shooting XT)
2nd wire (Miracle 12 g)
(F)
Figure 12.3 Use of parallel wire technique for ostial Left
Circumflex CTO after failed retrograde attempt. Baseline
angiography shows ostial LCx occlusion (panel A). Initial
wire entered the sub-intimal space and a new channel is
not easily created. Leaving the first wire in the sub-intimal
path, prevents the second wire to slip in it, and allows
other inside the CTO, as this will cause wire-twisting. Choice of the second wire is dependent on the
ease with which the first wire has advanced. The second wire could be of the same strength if the first
wire is advanced easily. Second wire should be stiffer
than the first one and should have a superior torqueability if the wire passage was difficult. These characteristics allow a better maneuverability of the second
wire and decrease the risk of wires twisting. Also, the
second wire should have the sharp primary curve to
allow directional change of the track. The wires that
we most commonly use as a second wire are the
Miracle 12 g, or a Confianza Pro wire (9/12 g), Gaia
3 wire, and/or Hornet 14 wires. As the second wire is
advanced along the same path parallel to the first
wire, we should apply only limited rotation. At best,
a 45–90° clockwise rotation followed by a similar
degree counter-clockwise rotation, and so on, should
be performed. The advancement of the wire should
be checked in multiple orthogonal angiographic
views, to confirm the correct location of the second
wire (Figure 12.2).
(C)
redirecting the second wire inside the CTO body. Stiffer
wire (Miracle 12) was used to direct towards the true
lumen with guidance and support of the first wire (panel
B, C, D), allowing entry of second wire in the distal true
lumen (panel E). Final result after stent implantation is
shown in panel F.
(D)
(E)
Philosophy of the technique: Parallel wires in the cor-
onary arteries stabilize the vessel course. A stabilized path enables easy wire path correction
advancement in the desired direction. This is not a
re-entry technique, and the second wire enters the
true lumen and directly into the distal cap, supported and guided by the first wire.
Double lumen microcatheter supported Parallel wire
technique: Increasingly double lumen (DL) catheters
with 2/3 distal wire exit ports such as Sasuke,
Crusade, and Re-cross are used during CTO recanalization. Parallel wire technique could be facilitated with the aid of DL catheters. If the first wire
enters the sub-intimal space, then DL catheter could
be loaded on this wire through the monorail segment. Second wire could then be loaded and
advanced through the monorail segment and after
exit could be maneuvered as described above (Figure
12.4). DL catheters provides more stability, less wire
twisting, and easy exchange of the guide wires, and
more importantly increases the pushing force of the
second wire by 3–4-fold.
112 PART IV Wires Technique
(A) (B) (C)(D)
(E)
LAO
View
RAO
View
Figure 12.4 Example illustrating the use of the parallelwire technique in Right Coronary CTO lesion supported by
Sasuke (Asahi Inc) Double Lumen Catheter. Contrast
injection allows visualizing the distal CTO end, and to
imagine the course of the occlusion on the baseline
angiography (panel A). A first wire GAIA 2 (Asahi Inc)
could cross the CTO body but was not able to penetrate
the CTO distal fibrous cap, sliding at this point into the
subintimal space (panels B). Parallel-wire technique was
Use of the parallel-wire technique
The parallel-wire technique can be used with different
aims, at different stages of the CTO recanalization:
Exchanging wires inside a CTO: When working with
the conventional single wire technique, we often
have to exchange the wire for another wire with different characteristics (increased stiffness, hydrophilic coating, tapered tip), or a different tip curve.
It is, however, difficult to pass the new wire through
the channel made inside the CTO by the previous
wire. When we have to exchange a wire, we essentially use the parallel-wire technique as it minimizes the risk of creating new false lumen or
perforations.
Finding a new channel inside the CTO body: In the
situation where the first wire enters a false lumen
or sub-intimal path, it can be difficult to find a new
path through the CTO body. Repeated wire manipulation causes wire to slip in the same subintimal
path. In this instance, leaving the first wire in the
subintimal path prevent the second wire to end up
in the same subintimal path. It is therefore easier to
manipulate the second wire along another path
thereafter undertaken using SASUKE Double lumen
catheter with first wire in the monorail segment. A second
wire (Confianza Pro 12) with sharp curve was passed
parallel to the first wire toward the true lumen and up to
the distal fibrous cap closely guiding the tip of the wire
towards distal true lumen in orthogonal views using first
wire as a guide (panel C and D). The second wire could
enter the distal true lumen of the RCA. Final result after
stent implantation is shown in panel E.
inside the CTO body. This can be achieved via
either truly parallel-wire course, or via contact of
the second guidewire against the first guidewire
which allows adjusting the direction of the second
wire (Figure 12.3).
Puncture of the distal CTO fibrous cap (Figures 12.2
and 12.3): The shape of the distal fibrous cap is
often dome shaped. When the wire tip reaches this
dome shaped distal fibrous cap, it often fails to penetrate and crossing it into the distal true lumen, but
instead slides along it into the subintimal space. In
this case, we should as well leave the first wire in
the subintimal space located around the distal CTO
fibrous cap, and bringing a second wire with a different tip curve (acute bend) along the same path
up to the distal fibrous cap. This is also recommended in case of tapered distal end of a CTO
which is more difficult to penetrate successfully.
Visualization of the distal true lumen and its relation to the first wire, as well as a stiffer wire, preferably tapered (Confianza 9/12 g, Gaia 3) with a
different wire tip curve increases the chance of
penetration and successful recanalization.
Clinical experience with the parallel
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wire technique
Parallel-wire technique can be applied to all CTOs,
irrespective of the individual lesion characteristics. In
one of our studies, 904 CTO recanalization were
attempted between 2002–2008 at Toyohashi Heart
Centre, Toyohashi, Japan. With the use of an antegrade approach with a single wire, successful recanalization was obtained in about 65% cases. The
parallel-wire technique was used in 30% of the cases,
and the predominant final wiring technique resulting
in the success in 10% of the cases [15]. Use of advanced
techniques such as IVUS – (intravascular ultrasound)
guided technique or retrograde approach further
improves the overall success rate to 90% as seen in
recent years [15]. In Expert JCTO registry involving
2596 patients, parallel wire technique was the final
recanalization technique in 14.4% of the cases to
achieve 89.9% successful recanalization rates [16].
Similar success rates were seen with the application of
the parallel wire technique in several other large
multi-centric registries [17–19]. In the recently published Global CTO crossing algorithm [20], parallel
wire technique is recommended in cases with good
distal vessel quality and visualization after the antegrade wire escalation fails. The general benefits of the
parallel-wire technique include a decreased fluoroscopy time as you spend less time exchanging wires
and trying to cross the lesion, reducing the amount of
contrast medium used as you can confirm the position of the wire by looking at the first wire without to
use a contrast injection. Parallel-wire technique could
allow higher rates of successful antegrade recanalization and preventing the need for more complex retrograde and ADR techniques.
Conclusion
During CTO angioplasty, when a first wire enters
the subintimal space, the parallel-wire technique
could be used to enter the distal true lumen. The
parallel-wire technique significantly increases the
success rate in percutaneous CTO recanalization via
antegrade route.
References
1 Stone GW, Rutherford BD, McConahay DR et al.
Procedural outcome of angioplasty for chronic total
occlusion: an analysis of 971 lesions in 905 patients. J Am
Coll Cardiol 1990; 15: 849–856.
2 Bell MR, Berger PB, Bresnahan JF, Reeder GS, Bailey KR,
Holmes DR, Jr. Initial and long-term outcome of 354
patients after coronary balloon angioplasty of total coronary artery occlusions. Circulation 1992; 85: 1003–1011.
CHAPTER 12 Parallel-Wire Techniques 113
3
Ishizaka N, Issiki T, Saeki F et al. Angiographic follow up
successful percutaneous coronary angioplasty of chronic
total coronary occlusion: experience of 110 consecutive
patients. Am Heart J 1994; 127: 8–12.
Kinoshita I, Katoh O, Nariyama J et al. Coronary
4
angioplasty of chronic total occlusions with bridging collaterals vessels: immediate and follow up outcome from a
large single-centre experience. J Am Coll Cardiol 1995;
26: 409–415.
5
Suero J, 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: 409–414.
Noguchi T, Miyazaki S, Morii I, Daikoku S, Goto Y,
6
Nonogi H. Percutaneous transluminal angioplasty of
chronic total occlusions. Determinants of primary success and long-term clinical outcome. Catheter Cardiovasc
Interv 2000; 49: 258–264.
7
Galassi AR, Grantham A, Kandzari D et al. Percutaneous
treatment of coronary chronic total occlusion. Part 2:
technical approach. Interv Cardiol Rev 2014; 9(3): 201–207.
8 Rathore S, Katoh O, Matsuo H et al. Retrograde percuta-
neous recanalization of chronic total occlusion of the
coronary arteries: procedural outcomes and predictors of
success in contemporary practice. Circ Cardiovasc Interv
2009; 2(2): 124–132.
Saito S. Different strategies of retrograde approach in
9
coronary angioplasty for chronic total occlusion.
Catheter Cardiovasc Interv 2008; 71(1): 8–19.
10 Brilakis ES, Grantham JA, Thompson CA et al. The ret-
rograde approach to coronary artery chronic total occlusions: a practical approach. Catheter Cardiovasc Interv
2012; 79(1): 3–19.
11
Brilakis ES, Grantham JA, Rinfret S et al. A percutaneous
treatment algorithm for crossing coronary chronic total
occlusions. J Am Coll Cardiol Intv 2012; 5(4): 367–379.
12 Thompson CA. The hybrid approach for percutaneous
revascularization of coronary chronic total occlusions.
Interv Cardiol Clin 2012; 1: 349–353.
Kimura BJ, Tsimikas S, Bhargava V, DeMaria AN, Penny
13
WF. Subintimal wire position during angioplasty of a
chronic total coronary occlusion: detection and
subsequent procedural guidance by intravascular ultrasound. Catheter Cardiovasc Diagn 1995; 35(3): 262–265.
14 Horisaki T, Surmely JF, Suzuki T. Contact wire technique:
a possible strategy for parallel wire technique. J Invasive
Cardiol 2007 Sep; 19: E263–4.
15 Rathore S, Matsuo H, Katoh O, Suzuki T et al. Procedural
and in hospital outcomes after percutaneous coronary
intervention for chronic total occlusions of coronary
arteries 2002 to 2008: impact of novel guide wire techniques. J Am Coll Cardiol Interv 2009 Jun; 2(6): 489–497.
16 Sekiguchi M, Muramatsu T, Kishi K, Muto M, Oikawa Y,
Kawasaki T, Fujita T, Hamazaki Y, Okada H, Tsuchikane
E. Assessment of reattempted percutaneous coronary
intervention strategy for chronic total occlusion after
prior failed procedures: analysis of the Japanese CTOPCI Expert Registry. Catheter Cardiovasc Interv 2019 Oct
1; 94(4): 516–524.
114 PART IV Wires Technique
17 Tsuchikane E, Yamane M, Mutoh M et al. Japanese mul-
ticenter registry evaluating the retrograde approach for
chronic coronary total occlusion. Catheter Cardiovasc
Interv 2013; 82(5): E654–61.
18 Teramoto T, Tsuchikane E, Matsuo H et al. Initial success
rate of percutaneous coronary intervention for chronic
total occlusion in a native coronary artery is decreased in
patients who underwent previous coronary artery bypass
graft surgery. J Am Coll Cardiol Intv 2014; 7: 17–19
19 Habara M, Tsuchikane E, Muramatsu T et al. Comparison
of percutaneous coronary intervention for chronic total
occlusion outcome according to operator experience
from the Japanese retrograde summit registry. Catheter
Cardiovasc Interv 2016; 87(6): 1027–1035.
20 Wu EB, Brilakis ES, Mashayekhi K, Tsuchikane E et al.
Global chronic total occlusion crossing algorithm: JACC
state of the art review. J Am Coll Cardiol 2021 Aug 24;
78(8): 840–853. doi: 10.1016/j.jacc.2021.05.055.
13
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CHAPTER 13
Transradial Approach for CTO
Lesions
Yutaka Tanaka* & Shigeru Saito
Shonan Kamakura General Hospital, Kamakura City, Japan
*Corresponding author
Introduction
In patients with stable ischemic heart disease undergoing percutaneous coronary intervention (PCI), the
transradial approach is recommended to reduce
access site bleeding and vascular complications. This
approach is a Class 1 recommendation with Class 1
evidence [1]. However, transradial intervention (TRI)
is not commonly performed in PCI for chronic total
occlusion (CTO) because of its inherent disadvantages. Nevertheless, if case selection is suitable and
cases are performed by experienced doctors, the
advantages of TRI can be gained along with reasonable success rates [2].
Advantages and disadvantages of
TRI for CTOs
The transradial approach facilitates an earlier time to
ambulation and lower rates of vascular and bleeding
complications, and it is especially effective in patients
who take anticoagulation drugs or are severely obese.
Hemodynamics can be unstable during or after complex procedures. In these situations, transradial
approach is beneficial for operators not to have to suspect groin access site complications.
However, the main disadvantage is the limited availability of guiding catheter sizes. The small size of the
radial artery causes hesitancy over the use of (7- or) 8-Fr
guiding catheters [3]. Moreover, the abnormal vessel
route from the radial to the ascending aorta is an impediment to guiding catheter insertion and stabilization.
Subsequently, this may lead to reduced guiding back-up
support and limited available devices and strategies.
Abnormal vessel route from the
radial to the ascending aorta
The subclavian or brachiocephalic artery may show
excessive tortuosity, especially in older patients.
Tortuosity can often be negotiated in regular TRI by
using stiff guidewire insertion or double guidewire
insertion to draw the guiding catheters into the coronary arteries. However, the tortuosity of the subclavian/
brachiocephalic artery makes the guiding catheter
unstable with poor back-up support. Moreover, it may
reduce the torque controllability of the PCI guidewires. Thus, if excessive tortuosity is found in the
subclavian or brachiocephalic artery (often in the right
radial artery), the approach site should be changed to
the opposite radial artery (left radial artery) or even to
the femoral artery (Figure 13.1).
Limitations of devices and strategies
A 7-Fr Glidesheath Slender (Terumo) with a hydrophilic coating and a thinner wall than those of conventional 7-Fr sheaths has enabled the use of 7-Fr
guiding catheters. However, the use of 8-Fr guiding
catheters remains limited. In the antegrade approach
for CTO, especially with a blunt or ambiguous
proximal cap, intravascular ultrasound (IVUS)guided wiring with simultaneous microcatheter use
may be required. When this strategy is assumed, the
8-Fr guiding catheter should be taken through the
transfemoral approach. The use of an 8-Fr guiding
catheter is mandatory for the combination of a double-lumen catheter and IVUS. In other situations,
most treatment strategies can be employed with TRI.
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.
115
116 PART IV Wires Technique
(a) (b)
(c)
(e)
(d)
Figure 13.1 (a) A 73-year-old female patient. The right
subclavian artery shows marked tortuosity and loop. (b)
The left subclavian artery is relatively straight. (c) The left
coronary artery (LCA) is cannulated by a 6-Fr EBU 3.5
guiding catheter (Launcher) through the left radial artery.
Two chronic total occlusion (CTO) lesions are in the
proximal left circumflex coronary artery (LCX) and the
distal left anterior descending artery (LAD). (d) The LAD
shows two critical narrowings in the proximal part and
one CTO lesion in the distal part. (e) Final angiogram after
stenting for both arteries.
CHAPTER 13 Transradial Approach for CTO Lesions 117
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Tips on guiding catheters
Most importantly, a guiding catheter ≧7-Fr should be
selected if the diameter of the radial artery allows it,
regardless of lesion morphology in TRI for CTOs. We
solely use Amplatz Left (AL) 1.0 or Amplatz Left Short
Tip (SAL) 1.0 (Launcher; Medtronic) for the right coronary artery (RCA), Extra back Up (EBU) 3.75 (Launcher)
for the left anterior descending artery (LAD), and AL 1.0
(Launcher) for the left circumflex coronary artery (LCX)
to obtain strong back-up support. Coaxial engagement
of the guiding catheter is essential for controlled wiring
with adequate push force.
In the case of a proximal RCA CTO, the side-branch
anchoring technique should be taken advantage of [4].
This basic technique is useful for strong back-up
support during the procedure, even with a 6-Fr guiding catheter (Figure 13.2).
Figure 13.2 (a) Proximal RCA shows chronic total occlusion
(CTO). (b) We use a 6-Fr SAL 1.0 guiding catheter with the
left radial approach. A 1.5 mm balloon is placed in the
conus branch and inflated by 4 atmospheres. (c) The
balloon anchoring in the conus branch holds the guiding
catheter tip against the right coronary artery (RCA). The
XT-A guidewire passes through the lesion. (d) After small
balloon dilatation, angiography shows whole RCA. (e) Two
stents are deployed under the balloon anchoring. (f) Final
result after stenting.
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