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118 PART IV Wires Technique
In the case of a more distal RCA CTO, compared
with side-branch anchoring, deep guiding catheter
engagement can provide stronger back-up support
(Figure 13.3).
Bidirectional transradial approach
Where possible, we recommend using the 7-Fr guiding
catheter for the retrograde approach. The points to note
for the bidirectional transradial approach are similar to
Figure 13.3 (a, b) Middle RCA shows chronic total
occlusion (CTO). (c) The 6-Fr SAL1.0 with the side-branch
anchoring is unsuccessful. (d) The 7-Fr AL1.0 deep
engagement facilitates controlled wiring with appropriate
back-up support. (e) Successful wire crossing. (f) Final
result after stenting.
CHAPTER 13 Transradial Approach for CTO Lesions 119
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those for the antegrade TRI. The distal radial artery is
increasingly used as an alternative access site. This is
advantageous owing to a low rate of post-procedure
radial artery occlusion and improved ergonomics for the
PCI operators in the case of left radial artery access [5].
Unsuccessful balloon catheter
crossing after successful wire
crossing
PCI operators may have difficulty passing devices
such as small balloons and microcatheters even after
successful wire crossing through the true lumen. This
is one of the major reasons for technical failure of TRI
for CTO. If calcification is observed within the lesion,
PCI operators should quickly change the strategy
to atherectomy using a Rotablator with a 1.25
mm
burr (Boston Scientific) for lesion modification.
Changing the CTO guidewire to a Rotawire Drive
is difficult. In such cases, a guide extension catheter
is inserted into the vessel, and a Tornus Pro (Asahi
Intecc) is advanced, rotating counterclockwise like a
drill. The Tornus Pro usually modifies and passes the
lesions (Figure 13.4). As a Rotawire Drive does not
pass smoothly through the Tornus Pro, the Tornus
Pro should first be exchanged with any microcatheter with a guidewire and then a Rotawire Drive is
inserted. Thus, a Rotablator can be used.
Figure 13.4 (a) 6-Fr SL3.5 guiding catheter is engaged
through the struts of the Sapien3 valve. Angiogram shows
middle LAD chronic total occlusion (CTO). (b) Gladius EX
assists crossing the lesion, but neither the microcatheter
nor the small balloon, including the Kamui XS (Asahi
Intecc), passes. (c, d) The Tornus Pro (Asahi Intecc) is
successful. (e) Rotational atherectomy is performed. (f)
Final result after stenting.
120 PART IV Wires Technique
Case selection of TRI for CTO lesions
We previously reported the prevalence of successful
and failed PCI for CTOs according to approach sites
and the J-CTO score [2, 6]. The transradial approach
had significantly lower access site-related major
bleeding than did the transfemoral approach.
Moreover, the transradial approach was comparable
to the transfemoral approach in terms of success rates
for the CTO, with J-CTO scores of 0, 1, and 2. In contrast, for complex CTOs with J-CTO scores > 2, the
transradial approach had a lower success rate than did
the transfemoral approach.
The advantages of the transradial approach may be
offset by the disadvantages regarding guiding back-up
support and available devices/strategies in the
treatment of complex CTO. Thus, our criteria for not
performing TRI for CTO lesions are as follows: (i)
when we cannot expect good back-up support from
guiding catheters; (ii) when we require complicated
techniques; or (iii) when we perform complex CTO,
particularly in cases with moderate or severe calcification. Appropriate case selection is essential for successful CTO treatment with TRI.
Conclusion
The transradial approach has significant advantages and
can be applied in the treatment of CTOs with various
measures. Importantly, application of the transradial
approach should be carefully considered in relation to
the difficulty of individual CTO cases.
References
1 Lawton JS, Tamis-Holland JE et al. 2021 ACC/AHA/SCAI
guideline for coronary artery revascularization: a report
of the American College of Cardiology/American Heart
Association Joint Committee on Clinical Practice Guidelines.
J Am Coll Cardiol 2022; 79: e21–e129.
2 Tanaka Y, Moriyama N, Ochiai T et al. Transradial coro-
nary interventions for complex chronic total occlusions.
JACC Cardiovasc Interv 2017; 10: 235–243.
3 Saito S, Ikei H, Hosokawa G, Tanaka S. Influence of the
ratio between radial artery inner diameter and sheath
outer diameter on radial artery flow after transradial coronary intervention. Catheter Cardiovasc Interv 1999; 46:
173–178.
4 Fujita S, Tamai H, Kyo E et al. New technique for superior
guiding catheter support during advancement of a balloon
in coronary angioplasty: the anchor technique. Catheter
Cardiovasc Interv 2003; 59: 482–488.
5 Tsigkas G, Papageorgiou A, Moulias A et al. Distal or tra-
ditional transradial access site for coronary procedures: a
single-center, randomized study. JACC Cardiovasc Interv
2022; 15: 22–32.
6 Morino Y, Abe M, Morimoto T et al. Predicting successful
guidewire crossing through chronic total occlusion of
native coronary lesions within 30 minutes: the J-CTO
(Multicenter CTO Registry in Japan) score as a difficulty
grading and time assessment tool. J Am Coll Cardiol Intv
2011; 4: 213–221.
14
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CHAPTER 14
Subintimal Angioplasty in
Coronary CTO
Negar Salehi1,*, Philippe Généreux2 & George D. Dangas
1
Mount Sinai Medical Center, New York, NY, USA
2
Cardiovascular Research Foundation, New York, NY, USA
* Corresponding author
Introduction
Chronic total occlusion (CTO) is the total obstruction of
a coronary artery for more than three months [1].
Successful percutaneous coronary intervention (PCI) for
chronic total occlusions represents one of the “last frontiers” in interventional cardiology. The true prevalence
of CTOs in the general population is unknown [2], In the
early 1990s, the CTO percentage was higher at about
50% in the thrombolytic era. This number has decreased
in the past two decades and is now seen in about 20% of
the patients who undergo coronary angiography [3].
However, recanalization is attempted in less than 15% of
CTO patients undergoing elective PCI [1, 4], mainly
because of the technical and procedural complexities [5].
Large studies of PCI in CTO lesions initially noted a procedural success rate of approximately 75% [6, 7].
Increasing experience, improved devices, technology,
understanding of the strategy, and the emergence of new
techniques like utilizing subintimal space have raised the
success rate to 90–95% [8, 9]. Lately, subintimal
angioplasty has been vital in advancing CTO-PCIs. This
chapter aims to present the basics of subintimal
angioplasty in different techniques for the CTO PCI.
Other CTO techniques will be done in other chapters.
Angiographic assessment and
strategy selection
A detail about the coronary anatomy is fundamental in
the CTO intervention and essential to success. Important
information could be determined from a pre-intervention diagnostic angiogram, including collateral details,
length of occlusion, and vessel course. Most of the time,
this information will be obtained by dual injection.
1,2
These points should be considered during dual injection,
like using wide-field, not panning, and prolonged cine to
get a collateral assessment.
Proximal cap, CTO body, distal cap, landing zone,
and collateral supply help with procedure strategy.
(Figure 14.1)
Subintimal angioplasty: The concept
The concept of bypassing the occlusion through the
subintimal space and then re-entering the true lumen
into or distal to the occlusion was first described in
the peripheral vascular literature in 1989 by Bolia et
al. [9, 11]. This technique has been extended to other
vessel sites [12–14] and coronaries [15].
Subintimal angioplasty aims to create a channel between the intima and the media using an intentional
dissection (Figure 14.2). Depending on the anatomy of
the lesion and the technique chosen by the operator, the
false lumen could be short, small, long, or large. In
addition, the false lumen can be created either anterogradely or retrogradely. As needed, a small balloon can
enlarge the false lumen. An IVUS catheter can also be
inserted into the false lumen to guide the re-entry of the
wire into the true lumen.
The guidewire will naturally tend to re-enter the true
lumen when it again encounters a normal patent vessel.
Re-entering the lumen in a favorable location may be
problematic when there is a significant disease or heavy
calcification in the vessel. It may be inadvisable to continue the dissection past major collateral vessels or into
run-off branches. Successful re-entry into the lumen is
usually heralded by a loss of resistance to the wire, which
will move freely into the true lumen. This can be confirmed by the injection of a small volume of contrast.
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.
121
122 PART IV Wires Technique
Figure 14.1 Components of the CTO vessel [10]. Brilakis et al,2019 / American Heart Association.
Figure 14.2 Schematic representation of subintimal angioplasty. (a) Subintimal angioplasty with a wire inserted between
the intima and the media creates a false lumen. (b) Propagation and enlargement of the false lumen.
The selection of appropriate wires for each step of
the subintimal angioplasty technique is crucial.
Generally, a hydrophilic wire with a prominent bend
is used to initiate and propagate the dissection and the
false lumen (Figure 14.3a, 14.3b). Conversely, a stiffer
wire is used to break back into the true lumen, and a
short 60–90° degree bend is preferred (Figure 14.3c).
approaches have failed. However, recent intravascular (IVUS) data suggest that subintimal tracking,
intentional or not, is frequent during successful
CTO–PCI [16]. Therefore, endoluminal recanalization should be the preferred option in very short
occlusions or where the anticipated re-entry zone
for subintimal angioplasty is short or heavily diseased. However, this technique may be difficult or
When to use the subintimal
angioplasty technique
unsuccessful for longer or more calcified lesions.
Therefore, familiarity with subintimal angioplasty
offers the operator an alternative approach and the
Most experienced CTO operators agree that subintimal tracking-related techniques should be used as
a second-line strategy when simple antegrade
ability to deal with inadvertent dissections.
Ideally, subintimal angioplasty techniques should
be reserved mainly for the right coronary artery and
CHAPTER 14 Subintimal Angioplasty in Coronary CTO 123
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Figure 14.3 (a) Wire tip shapes appropriate for
penetration of a proximal fibrous-calcified cap (Miracle 3).
(b) Wire tip shape properly for initiating subintimal
Antergrade
CTO
dissection/Rentry
strategy
Retrograde
Figure 14.4 Algorithm for CTO strategy.
possibly the circumflex. This approach for the left
anterior descending artery is not recommended and
should be restricted to specific situations and highly
experienced operators (Figure 14.4).
Subintimal angioplasty-related
techniques
Several techniques use the subintimal angioplasty
approach. Both antegrade and retrograde approaches
have been described using this concept. This section
will briefly describe the most currently used re-entry
techniques by CTO operators. Figure 14.5
STAR technique
Colombo first described the STAR (Subintimal Tracking
and Re-entry) technique in 2005 (Figure 14.6a) [18].
This approach creates a controlled subintimal dissection
with distal re-entry into the true lumen. Anterograde
STAR must be performed only in vessels with sidebranches distal to the expected re-entry site. This technique is usually performed when other approaches have
angioplasty and propagating false lumen (WhisperMS). (c)
Wire tip shape properly for re-entry from the false lumen
into the true lumen (Miracle 6).
STAR
Mini-STAR
LAST
Stingray
CART
Reverse CART
Dissection
Knuckle the wire
Dissection
Knuckle the wire
CrossBoss
Re-Entry
Re-Entry
Contrast- Guided STAR
failed or are not feasible and should not be considered a
substitute for the performance of traditional CTO
approaches. The ideal vessel for the STAR is the RCA,
and the least ideal is the LAD.
Classically, a hydrophilic wire with a pronounced
J-configuration is used for this purpose (Figure
14.3b). The hydrophilic wire is advanced through the
subintimal dissection plane. Once the wire has
reached the distal segment to the CTO, the tip of the
wire is gently deflected and redirected toward the
true lumen. However, because the guidewire has
already created a false lumen, it cannot be easily
advanced into the true lumen. Therefore, it is
mandatory to remove the wire over an exchange
catheter and exchange it for a stiffer wire. A moderately long 60–90° angulated bend will have a better
chance of successful re-entry into the true lumen
from the false lumen (Figure 14.3c). This technique
can convert negative dissection patterns into more
favorable types that allow recanalization of the true
lumen. However, it carries a high potential for perforation; therefore, only experienced operators should
attempt this technique.
124 PART IV Wires Technique
Figure 14.5 Illustration for contemporary SPM technique.
(a):The traditional SPM technique. The guidewire crosses
into the subintimal space, and angioplasty with a small
balloon is performed. The SPM length range was limited.
(b):The contemporary SPM technique. ADR was based on
Contrast-guided STAR
Carlino and colleagues described two modifications of
the STAR technique in 2008, where small injections of
contrast are used to track progression and to limit the
length of the false lumen [19, 20]. In this technique, stiff
wire is used to puncture the proximal cap, then advance
an over-the-wire balloon or microcatheter in the lesion.
After removing the wire, 1–2 cc contrast will be injected
with three possibilities: (1) Distal true lumen is visualized, and a floppy wire will advance to cross the lesion;
(2) Resistance to an injection without visualization of
the distal, then will advance the balloon further over
the wire and re-inject; (3) visualization of dissection.
The dissection can be in two scenarios: tubular vs.
storm cloud dissection. If there is a tubular dissection, a
linear contrast consistent with vessel outline, further
contrast will be injected to open the dissection into the
true distal lumen. However, if the storm cloud dissection is present, the recommendation is to terminate the
procedure or convert this type of dissection to the first
type [20].The potential advantage of a contrast-driven
dissection is that it delineates a road map of long
occluded segments, mainly when distal visualization
from the collateral flow is precarious. Another potential
advantage is that because the adventitial layer provides
greater resistance than the subendothelial layer, the
mechanical forces exerted by the contrast injection
could create a tear in the dissection flap and direct connection with the true lumen without the use of a wire.
This technique has been defined as the “hydrodynamic
recanalization” [19].
Mini-STAR
Similarly, Galassi has described the Mini-STAR technique or Limited Antegrade Subintimal Tracking
(LAST) technique. in mini-STAR, a Fielder FC or XT
the Stingray balloon and extensive guiding catheter.
ThisSPM technique was more aggressive, with a larger
balloon size and longer SPM length range. ADR: antegrade
dissection and re-entry; SPM: subintimal plaque modification.
(Source: JIA RF et al. (2020)/ Journal of Geriatric Cardiology).
wire (Asahi Intecc) achieves reentry. In contrast, in
the LAST, reentry will be performed by a Pilot 200
(Abbott Vascular) or Confienza Pro 12 (Asahi
Intecc) guidewire where the proximal cap of the
CTO is first penetrated. Then the STAR started into
the CTO segment, resulting in a shorter false lumen,
or occasionally with the help of a venture catheter (St
Jude, Minneapolis, Minnesota) [20] (Figure 14.6b).
In the Mini-STAR technique, two curves will be
applied to the wire: a 40–50 degree at the distal at
1–2 m proximal to the distal tip and a 15–20-degree
curve at 3–5 mm proximal to the tip [20].The wire is
advanced toward the CTO, causing true distal lumen
crossing, or the wire creates a J-loop that is advanced
for subintimal penetration of the CTO, followed by
efforts to reenter the true lumen as proximally as
possible, constraining the length of the dissection
plane [20].
CART
The CART (Controlled Antegrade and Retrograde
subintimal Tracking) technique was first described by
Katoh in 2005 and involved connecting the antegrade
and retrograde subintimal space (Figure 14.7) [21,22].
A wire is advanced in the antegrade direction from the
true proximal lumen into the subintimal space at the
CTO site. Another wire is advanced in the retrograde
direction via a collateral vessel into the true distal
lumen and then into the CTO subintimal space. A
balloon (1.25–1.5 mm) is advanced retrogradely into
the CTO subintimal space. It is inflated, enlarging the
space that is subsequently entered by the advance-
ment of the antegrade guidewire. However, retrograde
balloon advancement through a collateral vessel can
be challenging and may require multiple low-pressure
small balloon inflations for septal collateral vessel
CHAPTER 14 Subintimal Angioplasty in Coronary CTO 125
Retrograde
egrade
CART Reverse CART
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Figure 14.6 (a) Schematic representation of the STAR technique. (b) Schematic representation of the Mini-STAR
technique (presented at TCT 2010, Galassi).
Antegrade
Figure 14.7 Schematic representation of the CART and reverse CART technique. The arrow identifies the subintimal
dilatation balloon.
dilation. Occasionally larger diameter balloons may
fail to cross the collateral vessel [20].
The major limitation of the CART technique is that
the retrograde wire usually gets into plaque and not
into the subintimal space at the proximal part of the
distal CTO end. The retrograde balloon is then
inflated intra-plaque and not subintimal. Therefore, if
the antegrade wire is advanced into the subintimal
space at the site of retrograde balloon dilation, it could
be challenging to direct it into the true distal lumen.
Ant
Retrograde
Reverse CART
The basic concept of this technique is the same as
CART, except that the antegrade wire is used to create a
false lumen (Figure 14.7). The small balloon is inflated
over the antegrade wire in the subintimal space. After
navigating the previously created false lumen, the retrograde wire is manipulated through the collateral to find
the true lumen proximally. Once again, an IVUS catheter can be introduced in the subintimal space during
126 PART IV Wires Technique
re-entry of the true lumen [23]. Stent implantation
within the dissection has been proposed to provide a
more precise target for CTO crossing.
Since the development of the Corsair catheter
(Asahi Intecc), reverse CART has become the most
commonly used retrograde re-entry technique, as retrograde balloon access is not required.
Confluent balloon technique
The confluent balloon technique was described by
Wu et al. in 2009. It is a modification of the reverse
CART and CART strategies in which antegrade and
retrograde balloons are inflated simultaneously to
create a common subintimal space that will allow wire
crossing into the true lumen [20].
Intravascular ultrasound-guided
reverse controlled antegrade and
retrograde tracking – the IVUSguided reverse CART
Rathore et al. described a modification of the
reverse CART technique by using IVUS (IVUSguided reverse CART) [23]. After initial antegrade
balloon inflation with a small size (usually 2.0 mm)
balloon, an IVUS catheter is advanced in the antegrade direction into the CTO segment. This allows
the selection of an adequate-sized balloon based on
the vessel size and the presence of calcification
(smaller balloons are used in calcified vessels to
reduce the risk of perforation). After balloon
dilation, IVUS is used to visualize the connecting
channel, and if recoil is noted, a wire snare can be
used to keep the connecting channel open [23].
IVUS can then be used to visualize and confirm the
crossing of the retrograde guidewire into the true
proximal lumen.
Precise visualization of the entry point is crucial to
successful CTO recanalization. In particular situations, such as when a side branch originates very close
to the occlusion, angiography does not always allow
accurate visualization of the entry point. Instead,
images can be obtained via an IVUS catheter inserted
in a side branch close to the occlusion (Figure 14.8a).
Attempted wiring of the CTO can be performed
simultaneously during IVUS visualization. This technique has the advantages of avoiding the creation of
multiple false lumens after several failed attempts and
limiting contrast and radiation exposure.
IVUS can also guide re-entry from a false lumen
to a true lumen (Figure 14.8b) [23]. IVUS imaging
can precisely detect the start of the dissection and
the location of the true lumen. It can guide the pro-
gression of a second guidewire in the true lumen.
First, a guidewire advances into the subintimal
space, a subintimal space enlarged with a 1.5 mm
balloon catheter. Then IVUS catheter will be
advanced into the subintimal space, guiding wire
manipulation and re-entry of a stiff wire into the
true lumen.
Dedicated re-entry devices system
BridgePoint Medical (Minneapolis, MN) has a system
that facilitates re-entry consisting of the CrossBoss
catheter and the Stingray re-entry system. The
CrossBoss CTO catheter assists in reaching and
crossing occluded lesions by initiating or propagating
an intraluminal pathway through the lesion or creating a subintimal pathway past a CTO. The Stingray
CTO re-entry system consists of an orientating flat
balloon catheter that facilitates the re-entry of the
guidewire into the true lumen. In the Facilitated
Antegrade Steering Technique in Chronic Total
Occlusions (FAST-CTOs) trial, the Bridgepoint
system was used in 147 patients with 150 refractory
CTOs with 77% crossing success: the CrossBoss
crossed into the true distal lumen in 56 lesions, and
the Stingray balloon and wire facilitated distal true
lumen re-entry in 59 lesions [24]. In a series of 42
patients at four European centers, successful true
lumen distal wire passage was achieved in 67%
without any severe device-related complications [25].
Whitlow et al. reported successful re-entry in 16 of 19
cases with subintimal wire entrapment using the
Stingray system with one grade 1 perforation that did
not require any treatment [26].
In a multicenter cohort for CTO PCI with ADR
techniques, STAR had lower success rates than the
CrossBoss/Stingray system and LAST. In addition, the
CrossBoss/Stingray system was independently associated with a lower risk of MACE on follow-up compared to wire-based ADR techniques [27].
Conclusion
Subintimal angioplasty-related techniques represent
one of the significant advancements in CTO-PCI.
Mastering antegrade and retrograde re-entry techniques improve the success rate of CTO procedures and
improve clinical outcomes for patients. However,
regardless of benefits, re-entry techniques are inherently
complex and potentially dangerous in non-expert
hands. Therefore, adequate training and understanding
of the limits of subintimal angioplasty are warranted if
the full clinical potential of this approach is to be
realized.
CHAPTER 14 Subintimal Angioplasty in Coronary CTO 127
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Figure 14.8 (a) Intravascular ultrasound (IVUS)-guided
identification of the entry point of a chronic total
occlusion (CTO) via IVUS of a side branch. (b) IVUS over a
wire positioned in a false lumen, helping to position the
References
1 Touma G, Ramsay D, Weaver J. Chronic total occlusions –
current techniques and future directions. Int J Cardiol Heart
Vasc 2015 Jun 1; 7: 28–39.
2 Stone GW, Kandzari DE, Mehran R, Colombo A, Schwartz
RS, Bailey S et al. Percutaneous recanalization of chronically occluded coronary arteries: a consensus document:
part I. Circulation 2005 Oct 11; 112(15): 2364–2372.
second wire in the true lumen. IVUS imaging can precisely
detect the start of the dissection and location of the true
lumen and can guide the progression of a second
guidewire in the true lumen.
3 van Veelen A, Claessen BEPM, Houterman S, Hoebers LPC,
Elias J, Henriques JPS et al. Incidence and outcomes of chronic
total occlusion percutaneous coronary intervention in the
Netherlands: data from a nationwide registry. Neth Heart J Mon
J Neth Soc Cardiol Neth Heart Found 2021 Jan; 29(1): 4–13.
4 Muraca I, Carrabba N, Virgili G, Bruscoli F, Migliorini A,
Pennesi M et al. Chronic total occlusion revascularization:
a complex piece to “complete” the puzzle. World J Cardiol
2022 Jan 26; 14(1): 13–28.
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