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128 PART IV Wires Technique
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18 Colombo A, Mikhail GW, Michev I, Iakovou I, Airoldi F,
Chieffo A et al. Treating chronic total occlusions using
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Catheter Cardiovasc Interv Off J Soc Card Angiogr Interv
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19 Carlino M, Godino C, Latib A, Moses JW, Colombo A.
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21 Surmely JF, Tsuchikane E, Katoh O, Nishida Y, Nakayama
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22 Kimura M, Katoh O, Tsuchikane E, Nasu K, Kinoshita Y,
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23 Rathore S, Katoh O, Tuschikane E, Oida A, Suzuki T,
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24 Whitlow PL, Burke MN, Lombardi WL, Wyman RM,
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26 Whitlow PL, Lombardi WL, Araya M, Michael Wyman
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27 Azzalini L, Dautov R, Brilakis ES, Ojeda S, Benincasa S,
Bellini B et al. Procedural and longer-term outcomes of
wire- versus device-based antegrade dissection and reentry techniques for the percutaneous revascularization
of coronary chronic total occlusions. Int J Cardiol 2017
Mar 15; 231: 78–83.
15
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CHAPTER 15
Antegrade Dissection and Re-Entry
Techniques
Anbukarasi Maran*, Carson Keck & Matthew C. Evans*
Medical University of South Carolina, Charleston, SC, USA
*Corresponding authors
The inability to successfully pass a guidewire across a
lesion into the true lumen of the distal vessel is the most
common reason for Percutaneous Coronary
Interventions (PCI) failure in Chronic Total Occlusion
(CTO) [1, 2]. Antegrade Dissection Re-entry (ADR) is
an integral part of the Global CTO Algorithm [3].
There have been several different techniques that have
been described to improve the success rate of traversing
CTO lesions. Over the past several years, there has been
development of dedicated microcatheters and guidewires that have become the mainstay in the field of
CTO-PCI. In conjunction with the implementation of
many different recanalization techniques and improved
operator experience, the procedural success has also
increased [4–6]. There are four general approaches that
are used when crossing CTOS. These include antegrade
wire escalation, antegrade dissection and reentry, retrograde wire escalation, and retrograde dissection and
reentry. Prior to any procedure, skilled CTO operators
will evaluate the lesion characteristics and plan the
desired crossing strategy. While registry data consistently show that antegrade wiring is the most common
strategy for crossing CTOs, it is important to understand that to safely achieve a high success rate in CTO
PCI, expertise in dissection and re-entry techniques
and retrograde approaches are also required. In particular, longer lesions (>20 mm) with associated calcification and tortuosity are more difficult to cross with
wire escalation techniques and are more often successfully treated with dissection and re-entry techniques.
In antegrade dissection and re-entry (ADR), the operator intentionally creates a dissection plane across the
CTO segment and then re-enters the true lumen at or
beyond the distal cap. This is possible secondary to the
flexibility of the subintimal space which can easily accept
a wire with minimal hematoma. The development of
several newer technologies has also made targeted reentry back into the distal lumen more reliable, allowing
for preservation of important side branches.
The antegrade dissection can be created in several
ways:
1 Wire-based
Balloon-based
2
3
Catheter-based
4
Contrast-based
Wire-based
Subintimal tracking and re-entry (STAR) was the first
dedicated ADR technique to be described [7]. This technique involves pushing a wire, usually a polymer jacketed knuckled wire with low tip force, through the CTO
body. The wire is knuckled, similar to a blunt dissection
technique used in surgical procedures, until it reaches
the distal true lumen. The knuckled wire usually stays
within the architecture of the vessel and through a dissection plane past the CTO. The wire will advance
through the subintimal space until it is able to re-enter
the true lumen. The STAR approach is associated with
relatively uncontrolled re-entry to the true lumen. An
evolution of the STAR technique is the mini-STAR technique, where an attempt is made to wire the occlusion as
far as possible before entering a dissection plane. The
wire used is a polymer-coated guidewire with a
45-degree angle at the tip and a second 15-degree angle
4 mm from the tip. The wire is advanced toward the
CTO and either crosses into the true distal lumen or is
advanced for subintimal penetration followed by reentry. However, the mini-STAR technique does not
overcome the fundamental downside of STAR: that reentry cannot be controlled [8]. As a result, the STAR and
mini-STAR techniques have poor long-term results
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.
129
130 PART IV Wires Technique
Figure 15.1 ReCross™ Catheter [12].
with high rates of target vessel occlusion, side branch
loss and repeat revascularization [9].
The next evolution of a primary wire-based
approach is the limited antegrade sub-intimal tracking (LAST) approach. In this technique, a high tipload wire was used to cross the lesion. Once the wire
was noted to be in a sub-intimal location, the guidewire was exchanged via a micro-catheter for an alternative guidewire with a tapered tip, high penetration
force and large primary bend. The new guidewire is
angled with primary and secondary bends that facilitate puncture back into the true lumen. This technique was, however, also associated with unpredictable
re-entry location and less favorable outcome and with
the development of dedicated re-entry equipment for
ADR has largely been abandoned [10].
Balloon-based
Another technique that can be use is balloon-assisted
subintimal entry (BASE) or antegrade fenestration and
re-entry (AFR), typically used when there are impenetrable proximal caps [11]. Inflation of a balloon that is
sized 1:1 with the vessel, is inflated through the CTO
segment which aims to create tears within the vessel
media, thus allowing a soft polymer wire to cross fenestrations and reach the distal true lumen. More data is
needed regarding the reproducibility of this technique
including longer-term outcomes.
Catheter-based
The mainstay of targeted re-entry involves the catheter-based techniques. There are two main systems that
are commonly used for this purpose, including the
ReCross™ device and the CROSSBOSS™ Catheter and
STINGRAY™ LP system.
The ReCross™ device is an over-the-wire, dual
lumen microcatheter that has an additional exit port in
the tip lumen at a 180-degree angle to the standard exit
port (See Figure 15.1). This allows easier guidewire
re-direction and allows the operator to use and
exchange 2 different guidewires simultaneously.
The CROSSBOSS™ Catheter and STINGRAY™ LP
system was developed to create a controlled antegrade
dissection plane to allow for targeted distal vessel reentry (See Figure 15.2). This technique utilizes a blunt
tip dissection catheter to create delivery of the
STINGRAY™ balloon below the distal cap. The
CROSSBOSS™ catheter will either track through the
intimal plaque and re-enter the distal true lumen or
most commonly, create a dissection plane in the subintimal space. To accomplish this, the CROSSBOSS™
Catheter is advanced to the proximal cap. The torque is
then attached and with a fast spin technique and gentle
forward pressure the CROSSBOSS™ Catheter is slowly
advanced in the subintimal space distal to the distal
cap. The Stingray balloon is then traditionally used to
re-gain access to the true lumen. Similar to the
ReCross™ device, the STINGRAY™ balloon has two exit
side ports that are 180 degrees apart. With low atmosphere inflation, one port will be oriented facing the true
lumen and the other will be facing away from the true
lumen. The STINGRAY™ wire is then used to puncture
the intimal flap and facilitate re-entry into the true
lumen. The use of this system allows for a controlled
site of vessel re-entry which creates reproducibility of
this technique. Because of the predictability, this has
become the most commonly used mode of ADR.
CROSSBOSS™ Catheter Step by Step Approach:
1 Delivery of the CROSSBOSS™ to the proximal cap
a Access the CTO proximal cap via a workhorse
guide wire
b Advance the CROSSBOSS™ catheter to the
proximal cap
c Retract the guidewire into the catheter
2 Position the CROSSBOSS™ catheter torque 2–3cm
proximal to the Y-connector
3 Rotate the CROSSBOSS™ catheter using the fast-
spin technique and gentle forward pressure
a Hold the Y-connector between the small finger
and the palm of the left hand
CHAPTER 15 Antegrade Dissection and Re-Entry Techniques 131
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Figure 15.2 CROSSBOSS™ Catheter and STINGRAY™ LP system [13].
b Rotate the torque device using the index finger
and thumb of both hands
c Faster spinning with reduce friction and increase
likelihood of advancement
4 Assess the CROSSBOSS™ position
a
If failed to advance:
Increase guide catheter support
i
ii
If hard, calcified proximal cap, try a stiff
guidewire to puncture the cproximal cap
<5–10 mm. Withdraw the wire and move
back to the fast-spin technique
iii Transition to a wire-based strategy
b If enters a side branch:
i This is a potentially serious complication
which could lead to large perforation
ii
Retract the CROSSBOSS™ catheter and redi-
rect, usually with a knuckled polymer-jacketed guidewire
c If partially crossed the occlusion:
i Retract and redirect the CROSSBOSS™ cath-
eter
d If crossed into subintimal space distal to the
distal cap
i This creates favorable conditions for re-entry
ii Utilize the STINGRAY™ balloon for reentry
iii Remove the CROSSBOSS™ over a stiff,
straight guidewire
e If crossed into the true distal lumen:
i A Insert a workhorse wire into the true
distal lumen and remove the CROSSBOSS™
catheter
The contemporary ADR technique
Contemporary ADR is the newest iteration of ADR in
which many changes have been made since the initial
ADR in 2018. The overall goal of contemporary ADR
is to limit exposure of the dissection plane to antegrade arterial pressure. This is done by removing side
holes from the guide catheter. A TrapLiner® guide
extension is also used at the outset of the procedure
and the number of antegrade wiring attempts are
minimized. In contemporary ADR, we strive for a single catheter exchange mainly the microcatheter to the
STINGRAY™ system. Lastly, balloon inflations are
limited beyond the proximal cap.
Contrast-based
In 2008, a contrast-guided STAR technique was
described [14]. In this technique, a stiff guidewire is
used to puncture the proximal CTO cap. After the cap
is sufficiently punctured, the distal tip of a microcatheter or over-the-wire balloon is inserted into the
lesion. The guidewire is then removed and 1 to 2 cc of
contrast is injected into the CTO. The contrast injection will allow for several possibilities:
1 Visualization of the distal true lumen
a This will allow for crossing of the lesion with a
workhorse guidewire
2 No distal visualization and resistance to injection
b A guidewire should be used to advance deeper
into the lesion after which contrast should be
injected again
132 PART IV Wires Technique
3 Dissection visualization
a Tubular dissection – linear contrast opacification
i Perform additional injections to open the
dissection into the distal true lumen
ii If contrast injections are unsuccessful, a poly-
mer jacketed knuckle wire should be inserted
and advanced into the true distal lumen.
b Storm cloud dissection – diffuse staining
i Abort the procedure
This technique was reviewed by Carlino et al. in a
group of 68 patients. It was noted to be successful in
81% of patients with restenosis in 45% of patients on 7
month follow-up [14]. Based on these results, this
method is only recommended after of failure of standard antegrade and retrograde techniques.
Contemporary ADR example
(Figure 15.3)
Now that we have described all of the techniques commonly used in contemporary ADR, we will walk
through an example. This was a patient who had
severe left main stenosis with a CTO segment of the
dominant circumflex. The CTO PCI had been
attempted twice by another operator twice. On the
second attempt, the operator attempted the STAR
technique but was unable to get back into the true
lumen. The CTO segment was noted to have a shorter
length of <20 mm with minimal calcification and tortuosity. The vessel was also noted to be filling in and
out of dissection planes.
We started the case with a microcatheter and a Pilot
200™ and went into the dissection plane. We then
immediately exchanged the Pilot 200™ for the
STINGRAY™ balloon. Re-entry was done with GAIA
3 NEXT® wire. Reentry to true lumen was established.
A stick and drive technique was used in which we
used the same wire to complete the procedure. IVUS
guided PCI was then completed.
Troubleshooting
When completing CTO PCI, there are several issues
that can arise that the CTO operator should be comfortable navigating. The first of these is difficulty
knuckling the wire. This typically occurs when there
is an impenetrable proximal cap. One technique that
can be used in this scenario is balloon-assisted subintimal entry (BASE). A balloon, sized 1:1 with the vessel, is inflated proximal to the CTO to create intimal
disruption, and a microcatheter is then positioned
alongside. This increases support and allows passage
of a knuckle wire into a dissection plane [8]. A Carlino
technique can also be used where contrast is injected
through the microcatheter. The contrast will initiate
the dissection and then the wire can create the
knuckle.
Another downfall that can occur during PCI is the
inability of the device to cross secondary to proximal
vessel calcifications [3]. The techniques that should be
used in this situation include:
1 Increase the amount of support by Amplatzing the
guide, guide extension, or anchor balloon
2 Use small balloons (1.5 mm x 20 mm) for
pre-dilation
3 Balloon assisted microdissection (BAM) with the
same small balloon
4 Dotter catheter (Turnpike gold® or Tornus®)
5 Laser atherectomy/on contrast
6 External cap crush – go into the direction plane
and crush the cap from behind
7 Carlino Technique
8 Use microcatheter to deliver a short wire for rota-
tional atherectomy
If calcification is present in the landing zone, you
may want to try different wires to re-enter through
your StingRay. Examples of wires that can be used are
the Astado® 20, Gaia 3 Next®, and Hornet™ 14. The
bend of the wire may also need to be changed to a
steeper angle to assist in getting through the calcium.
Figure 15.3 Example of a CTO PCI of a dominant left
circumflex artery. A: Initial angiogram demonstrating
severe left main disease with a dominant circumflex CTO.
The CTO segment is filling via dissection planes. B: The
Stick and Drive Technique is used to cross the lesion. C:
Final angiographic results.
CHAPTER 15 Antegrade Dissection and Re-Entry Techniques 133
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The specific techniques that are commonly used are
the Stick and Drive technique, the Stick and Swap
technique and the Bobsled technique. In the Stick and
Drive technique, the same wire is used to re-enter the
true lumen and complete the PCI. In the Stick and
Swap technique, after re-entering the true lumen, you
exchange for a friendlier wire, such as a Pilot™ 200.
Lastly, the Bobsled technique is done by moving the
STINGRAY™ system forward or backward. This is typically utilized when the location of re-entry is not ideal.
When a side branch is present at the proximal cap,
a dual lumen catheter can be used with the second
lumen allowing wire cannulation of the correct vessel.
A modification of the BASE technique, the side-BASE,
can also be used. In this technique, a blocking balloon
is positioned in the side branch causing deflection of
the knuckle wire into a dissection plane in the main
vessel. A Pilot™ 200 wire could also be attempted as it
has a larger knuckle avoiding the side branch.
During CTO PCI, if your landing zone disappears
this is usually secondary to compression from a subintimal hematoma. This can be mitigated with a
Subintimal Transcatheter Withdrawal Technique
(STRAW) with a StingRay balloon, microcatheter or
over-the-wire balloon. A Blind Stick can also be
attempted. During this technique, the operator will
stick through both ports of the STINGRAY™. The wire
should then be exchanged for a friendlier wire.
Problem to Solve Possible Solutions
Cannot start a Knuckle •
Calcification • Grenadoplasty
Side Branch • Dual lumen catheter
Landing Zone disappeared • STRAW
Nowhere to land • Bobsled
BASE
• Carlino
• IVUS to size the balloon
•
ROTA
• LASER
• Stiffer wires for re-entry
• Stick & Swap
• Stick & Drive
• IVUS imaging
• Side-BASE
• Pilot Knuckle
• Blind Puncture
• IVUS imaging
• Double ADR into
branches
need for high pressure contrast injection which can
create or propagate dissection. IVUS should be used
in the tradition mechanisms to identify stent sizing
and assessing stent apposition and expansion. Specific
to the CTO PCI, IVUS can assist in determining the
course of the wire. This will allow the operator to
identify where the wire is in the false lumen and how
it relates to side-branches thus decreasing unintentional side branch loss and periprocedural MI.
An additional strategy that can be utilized to assist
in the planning of CTO procedures is coronary computed tomography angiography (CTA)/fluoroscopy
co-registration. This can generate a three-dimensional
view that can guide antegrade dissection and re-entry
strategy. This technology will fully define the proximal cap, allow for precise navigation of the dissection
trajectory and selection of the most optimal re-entry
site [16].
Outcomes
ADR has been increasingly used in the contemporary
era given the increasing complexity of lesions and
evolution of available equipment. Analysis of the
RECHARGE registry demonstrated that the use of
ADR resulted in nearly 90% success for CTO PCI
[17]. In subgroup analysis, the CROSSBOSS™ Catheter
and STINGRAY™ LP system had 81% success [18].
The most common reason for failure of ADR was
either the formation of a distal hematoma at the landing zone or failure of the equipment to reach the distal
landing zone [18]. These techniques appear relatively
safe, however do still carry a 0.4–5%% risk of perforation and higher risk of periprocedural myocardial
infarction. For this reason, the use of antegrade subintimal dissection and reentry technique are typically
used as a second- or third-line strategy when conventional crossing attempts have failed.
As discussed above, the first described ADR for
CTOP PCI was the STAR technique which was associated with high rates of restenosis. The following iterations with the contrast-guided STAR technique,
Mini-STAR technique and the LAST technique also
showed high rates of in-stent restenosis with 1-year
MACE rates of >15%. A more recent study looking at
device-based ADR, which is now in contemporary
practice, demonstrated that this technique had significantly lower MACE (~4–7%) with lower rates of
re-stenosis [19].
Intravascular imaging in ADR
The use of intravascular imaging significantly reduces
target vessel failure in non-occlusive disease [15]. The
preferred modality is IVUS over OCT as it avoids the
Conclusion
ADR remains an essential technique for successful
CTO PCI. This strategy is a safe and efficient means to
achieve revascularization in longer, more complex
134 PART IV Wires Technique
lesions. Once a dissection plane has been created,
whether it be by predominantly wire- or catheterbased approaches, the distal lumen can be re-entered
preferably in a controlled fashion in order to maintain
important side branches. Interventionalists who wish
to perform CTO PCI should familiarize themselves
with dissection and reentry techniques.
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16
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CHAPTER 16
3D Wiring Methods in CTO PCI
Atsunori Okamura
Cardiovascular Center, Sakurabashi Watanabe Hospital, Osaka, Japan
Introduction
The coronary artery is a three-dimensional (3D)
structure, therefore 3D wiring has a great advantage in
chronic total occlusion (CTO) percutaneous coronary
intervention (PCI) which requires accurate guidewire manipulation. Fifteen years ago, we proposed to
Terumo Corp. (Tokyo, Japan) about the development
of a CTO specific intravascular ultrasound (IVUS),
and Navifocus WR IVUS was developed in 2012 [1, 2].
After that, while performing IVUS guided
recognized the importance of guidewire manipulation
under 3D images and established the following 3D
wiring methods (Figure 16.1). (1) Angiography-based
3D wiring [3, 4], (2) AnteOwl WR IVUS (AO-IVUS,
Terumo Corp)-based 3D wiring for intraplaque
tracking [5–8], and (3) AO-IVUS-based 3D wiring for
antegrade dissection and reentry (ADR) (tip-detection ADR; TD-ADR) [9, 10]. Most of the CTO cases
can be treated by the procedural flow from (1) to (3)
in the antegrade approach (Figure 16.2) [10]. Among
the 3D wiring, IVUS-based 3D wiring of (2) and (3)
is very effective and reliable, and it will change the
strategy of CTO PCI in the world. Unfortunately, as
of 2022, the CTO specific IVUS with a short-tip and a
pull-back transducer system such as AO-IVUS is only
available in Japan, and it is difficult to perform the
same level of 3D wiring overseas as in Japan. However,
3D wiring consists of many various methods accumulated over a period of more than 10 years, and there
are parts that can also be used overseas in various situations. We hope that you have read this content and
that you have made use of some parts of 3D wiring. In
wiring, we
addition, we hope that the spread of this content will
make it possible to use the CTO-specific IVUS such as
AO-IVUS outside Japan.
Basic concept of guidewire
manipulation for 3D wiring in CTO
lesions
First, we describe how the PCI CTO stiff wires move
inside the CTO lesion (Figure 16.3A). The usual shape
of the guidewire for a CTO lesion has only the 1stcurve with 45 degrees and 1
wire is rotated inside a solid CTO tissue, the shaft
is fixed and only the tip is rotated like a pivot-like
movement. The 3D wiring method applies this pivotlike movement. However, as the tissue collapses during the guidewire manipulation, it becomes difficult
for the shaft to be fixed in the tissue, and the shaft also
begins to move, reducing the accuracy of the guidewire manipulation in the 3D wiring.
In order to perform the 3D wiring method, it is
necessary to understand the guidewire manipulation. When advancing the guidewire inside the CTO
lesion, there are only two manipulations: rotation and
advancement. Unlike common guidewire manipulations such as searching with operator’s tactile feeling,
which do not clearly separate the two movements,
the 3D wiring requires clear recognition of these two
manipulations and accurate advancement of the guidewire toward the target. In other words, it is required for
the operators to accurately advance the tip of the guidewire to the target based on the 3D images by controlling
a torque 140 cm away from the tip (Figure 16.3B).
mm. When the guide-
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.
135
136 PART IV Wires Technique
In 2012, CTO specic IVUS
AWE
AO-IVUS
-wire
Second monorail lumen (26 cm)
Navifocus WR IVUS
Transducer
with 40 MHz
9 mm
2.5 Fr
In 2014, angiography-based 3D wiring
3D
imaging rule
RAO 30°
In 2019, IVUS-based real-time 3D wiring
Second monorail lumen (26 cm)
Ante Owl WR IVUS (AO-IVUS)
15-cm pull-back
In 2021, Tip detection-ADR
Vertical penetration
Tip-detection-ADR (TD-ADR)
Figure 16.1 Process of establishing 3D wiring to standardize accurate guidewire manipulation in CTO PCI.
Antegrade wire escalation
(AWE)
LAO 60°
8 mm
Subintima
GW tip
Entrance
Transducer
with 40 MHz
2.5 Fr
CTO
Intraplaque
st
1
-wire
Intima
Calcication
Tip dete ction method
Subint ima
Exit, distal true lumen
Tip
Subintima
Insertion of
AnteOwl WR-IVUS
Angiography-based
Parallel wiring
or Stingray-ADR
Figure 16.2 CTO algorithm of antegrade approach with 3D wiring methods including AO-IVUS.
Angiography-based 3D wiring
technique
Immediate 3D image construction from
two orthogonal fluoroscopic
observations using the 3D imaging rule
Among the 3D wiring methods, angiography-based 3D
wiring is complicated and has low accuracy. However,
fluoroscopy (angiography)-guided guidewire manipulation is fundamental to CTO PCI. Whether or not angiography-based 3D wiring can be performed in clinical
practice depends on whether 3D wiring can be performed
No
Fail
Yes
AO-IVUS-based
or
Intraplaque tracking
(IVUS-parallelwiring)
or TD-ADR
AO-IVUS-based intraplaque tracking
CTO
Calcication
Intraplaque
AO-IVUS
nd
-wire
2
1st-wire
AO-IVUS-based TD-ADR
CTO
Calcication
Intraplaque
2nd-wire
st
1
accurately with reproducibility using the Rotational
ETOSS model (Asahi Intecc Co., Ltd.) (doi: 10.1007/
s12928-022-00861-3) [11], which is described later. There
are two key points for 3D wiring. First, rotation of the
torque and the tip of the guidewire should be
synchronized. This technical point can be acquired by
performing this synchronization even in open vessel PCI
procedures. Second, immediate 3D image should be
constructed from two orthogonal fluoroscopic observations. The method of creating a 3D image from images
obtained in 2 perpendicular directions is explained in
the following [3, 4]. To create a 3D image of the guidewire
CHAPTER 16 3D Wiring Methods in CTO PCI 137
A.
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The guidewire movement in the CTOlesions of solidtissueispivot-like
movement.The shaft is xed, andthe tiprotates around the shaft.
CTO lesion of solid tissue,
but not fragile tissue
B.
Control the tip 140 cm away from
our hands
Using the uorography
or IVUS, accurately
penetrate the target using
the 3D images
Shaft
Tip
Pivot-like movement
Target
Figure 16.3 How to achieve accurate guidewire manipulation with the 3D images in CTO PCI.
and its target, the guidewire should be divided into shaft
and tip sections and their positional relationship with the
target is assessed. There are 64 possibilities for the rotational angle when the wire tip is oriented at 45 degrees to
the target (Figure 16.4) [3]. In order to quickly create a
3D image when wiring a CTO, the following “3D
imaging rule” should be applied. The 3D imaging rule is
“The object (shaft or tip) is always in front (behind) on
the next image after rotation if the object is in the same
(opposite) direction as the rotational direction of the
X-ray detector,” and simplified, “The same is in front and
Longitudinal image
Cross-sectional image
the opposite is behind.” The left to right direction and the
up to down direction on the monitor should both be
united with the rotational direction of the detector, so
that 3D image of the wire and its target can be obtained
at any location in the coronary arteries irrespective of
coronary anatomy. Figure 16.5 displays how to use the
3D imaging rule [3, 4]. (1) The guidewire is divided into
shaft and tip sections. (2) Next, the left to right and up to
down directions on the monitor are united with the rotational direction of the detector. Accordingly, the object
seen by the detector should be understood as shown on a
Shaft
Tip
RAO 30°
Vessel
Target
LAO 60°
Target
• Route in CTO body
•CTO exit
•Retrograde GW
Figure 16.4 Sixty-four possibilities for the rotational angle when the wire tip is oriented at 45 degrees to the target.
LAO 60°
Target
LAO 60 °RAO 30 °
C = Clockwise
CC = Counterclockwise
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