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148 PART IV Wires Technique
A.
B.
Figure 16.20 Procedural details about the tip detection method for intraplaque tracking.
Figure 16.21 Demonstration of the tip detection method in AO-based 3D wiring using the experimental CTO model.
Terumo Medical Corporation / https://www.youtube.com/watch?v=gXJV8KT9uvc / last accessed Febuary 02, 2023.
Representative case of AnteOwl-based
3D wiring using the TD method [6]
A man in his 50s suffered from effort angina pectoris due to a CTO lesion in the midportion of the
left circumflex coronary artery (LCX). The first
PCI was performed on this lesion (Figure 16.22A).
As there were no retrograde channels, AWE
strategy, including parallel wiring and Navifocus
WR-IVUS-guided wiring, was applied. However,
the guidewires could not be passed through the
CTO lesion and a huge subintimal space was created (Figure 16.22B, 16.22C).
After commencement of the clinical use of
AO-IVUS, a retry PCI procedure was performed
on this CTO lesion in the LCX. An 8Fr guide catheter was inserted from the femoral artery. Coronary
angiography showed the same angiographic image
of the CTO lesion in the LCX as before the first PCI
procedure (Figure 16.22D). The first guidewire (XTR) supported by a Corsair microcatheter was advanced
and seemed to enter the subintimal space created by
the previous procedure. The Corsair microcatheter
was advanced 2 cm beyond the entrance of the CTO to
create a space for the IVUS catheter, and the XT-R was
CHAPTER 16 3D Wiring Methods in CTO PCI 149
1st-procedure
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AB
Entrance
of CTO
Huge subintimal
space
Exit
of CTO
2nd-procedure
DE
Entrance
of CTO
Exit
of CTO
Figure 16.22 Angiographic and IVUS images during first and second procedures.
A
Entrance
of CTO
Exit
of CTO
Side
branch
B
Subintima
1
2
3
4
1
Intraplaque
Exit lumen of
CTO
st
-wire
Calcication
Side branch
1
2
3
4
C
Subintimal space
F
IVUS
Subintima
Subintima
Subintima
Intimal space
st
1
-wire
Intraplaque
st
1
-wire
Calcication
Acoustic shadow
Intraplaque
st
-wire
1
Intraplaque
Side branch
st
1
-wire
Intraplaque
Figure 16.23 2nd-procedure: Pre-procedural angiographic image and IVUS images through the 1st-guidewire route.
changed to an Ultimate Bros3 wire (Asahi Intecc) to
obtain good support for advancing the IVUS catheter.
Figure 16.24 shows the pre-procedural angiographic
image and IVUS images (Figure 16.23A, 16.23B),
which revealed that the guidewire entered the subintimal space at the exit site because of the presence of
calcification (Figure 16.23B, 2).
First, we transferred the positional information of
the vascular structure from the IVUS image to the
angiographic image using the tip detection method as
described above. Then, we performed IVUS-based 3D
wiring using the tip detection method. The second
guidewire (Confianza-12g; Asahi Intecc) supported
by the Corsair was advanced and AO-IVUS-based 3D
Vessel lumen
150 PART IV Wires Technique
Tip of 2nd-wire and its direction
1
-wire
After counterclockwise rotation of the 2nd-wire
2
Figure 16.25B shows the patient and lesion characteristics and procedural outcomes. More than half
of the lesions were re-attempted lesions. The mean
Japanese chronic total occlusion score was 2.3 ± 1.0.
An 8 Fr guiding catheter was used in 93% of cases.
In one case, a 7 Fr guiding catheter was selected,
and a Corsair and AO-IVUS could be easily inserted
into the 7 Fr guiding catheter. The most common
procedure performed prior to the AO-IVUS-based
3D wiring was AWE (AWE: 80%, followed by AWE
to RWE: 13%, finally AWE to ADR: 7%). After being
able to advance the Corsair with or without balloon
dilation, AO-IVUS could be advanced in all of the
lesions. The main microcatheter used for the second
guidewire was the Corsair because it was used for the
first guidewire manipulation. In 14 out of 15 cases,
the second guidewire successfully crossing the CTO
IVUS
Calcication
Subintima
nd
-wire
B
1st-wire
Subintima
1
2
3
4
Intraplaque
Exit lumen of
CTO
Routes of
nd
2
Calcication
Side branch
A
Corsair
2
IVUS
transducer
IVUS tip
Figure 16.24 AO-IVUS based-3D wiring using the tip detection method.
wiring using the tip detection method was performed
5 mm before the exit (Figure 16.24A). The second
guidewire was rotated counterclockwise to direct its
tip to the intraplaque area where the exit lumen was
located further distally (Figure 16.24B, 1). The guidewire was then advanced and entered the exit lumen
(Figure 16.24B, 2). However, the tip was directed to
the side branch, and therefore the guidewire was
rotated clockwise to direct its tip to the main branch
(Figure 16.24B, 3) and was advanced into the distal
part of the main branch (Figure 16.24B, 4). AO-IVUSbased 3D wiring, performed in only 8 minutes,
allowed the second guidewire to be accurately
advanced to the exit lumen. The CTO lesion was
dilated with one drug-eluting stent and normal antegrade blood flow was achieved (Figure 16.22E,
16.22F).
lesion in the AO-IVUS-based 3D wiring was the
Initial outcomes of AO-IVUS-based 3D
wiring using the tip detection method in
CTO PCI [8]
From October 2019 to August 2020, a total of 88 consecutive patients underwent PCI for CTO recanalization at Sakurabashi Watanabe hospital. Among the
four major CTO revascularization strategies; AWE,
retrograde guidewire escalation (RWE), antegrade
dissection re-entry (ADR), and the AO-IVUS-based
3D wiring, the AO-IVUS based 3D wiring was chosen
as much as possible while referring to the CTO algorithms. Out of these, a total of 15 consecutive patients
(15 lesions) who underwent the AO-IVUS-based 3D
wiring were retrospectively enrolled in the present
analysis (Figure 16.25A).
Conquest (Confianza) wire series (Asahi Intecc Co.,
Ltd.), because 3D wiring is a technique to advance the
guidewire by a pure penetration method. The average
wiring time on the AO-IVUS-based 3D wiring to
pass through the CTO lesion was only 7.3 ± 4.5 minutes. The success rate of the AO-IVUS-based 3D wiring was 100%. No in-hospital major adverse cardiac
and cerebrovascular events were found. Compared
to Navifocus WR IVUS-based conventional wiring, which has been performed by Eagle Eye IVUS
outside of Japan, AO-IVUS-based 3D wiring using
the tip detection method markedly increased the success rate of IVUS-guided wiring in CTO PCI (100%
of cases [n = 15/15] vs. 63% of cases [n = 10/16],
respectively, P <0.01) (Figure 16.25C).
1st-wire
Intraplaque
Intraplaque
Intraplaque
3
After slightly pullback and 90º clockwise
rotation of the 2nd-wire
4
Subintima
Intraplaque
Subintima
Subintima
Intraplaque
Distal lumen
Intraplaque
Distal lumen
Lumen of
side branch
Shaft of
2nd-wire
CHAPTER 16 3D Wiring Methods in CTO PCI 151
A.
14 Retry151 mm-POBA, CorsairConquest-20g Success
)
B.
C.
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88 consecutive CTO PCI cases
from Oct. 2019
Aug. 2020
n = 88
Primary
AWE
n = 85
Primary
RWE
n = 3
Rescue
RWE
n = 9
AO -IVUS
based-3D
wiring
n = 12
CTO lesion
(AHA)
13 De novo 4Corsair Conquest-12g Success
9Retry 5Finecross Conquest -9gSuccess
13 Retry81 mm -BA, CorsairConquest-9g Success
13 Retry9 CorsairConquest-12g Success
7De novo 5Corsair Conquest-12g Success
7Retry 19 CorsairGaia next 3rd Success
15 De novo 5Corsair Conquest-12g Success
2De novo 8Corsair Conquest-12g Success
13 Retry5 -BA, CorsairConquest-9g Success
2Retry 8Corsair Conquest -12g Success
11–13 De novo 4Corsair Conquest -12g Success
7De novo 2-BA, CorsairConquest-12g Success
11 De novo 9Corsair Conquest -20g Success
7De novo 8Corsair Conquest-12g Success
De novo
/Retry
IVUS guided
wiringtime
(min)
Pre-dilatation
1.5 mm
1.5 mm
AO -IVUS
based-3D
wiring
n = 2
Crossing wire in
IVUS guide
AO -IVUS based -3D
(Tip detection-ADR)
Success/
Failure
ADR
n = 7
wiring
n = 1
Comparison of initial success rates of the two
IVUS guided wiring in CTO PCI
100
80
60
40
20
0
63%
Fusion method
By Navifocus -WR
(Non pull back, short tip)
(n = 16)
–2014
2012
By AnteOwl-WR
(Pull back, short tip
100%
TD method
(n-15)
2019–2020
Figure 16.25 Initial outcomes of consecutive 15 CTO cases treated with AO-IVUS-based 3D wiring using the tip detection
method.
TD-ADR case). We named this method “tip detectionADR (TD-ADR)” [9]. It is a re-entry method that
accurately punctures the wall by visualizing the apex
of the guidewire tip using the tip detection method,
similar to echo-guided venipuncture. Since the article
of Reference 9 (doi: 10.1007/s12928-022-00846-2.) is
open access, please refer to our video of the first intentional reentry by TD-ADR.
AO-IVUS-based 3D wiring for ADR
(TD-ADR)
TD-ADR: IVUS-guided ADR by the tip
detection method
To date, it has been considered impossible to standardly
perform ADR without using a re-entry device (Stingray
system; Boston Scientific, Natick, MA, USA) [12].
However, while performing the above AO-IVUS-based
intraplaque tracking using the tip detection method,
we first found in August 2021 that the tip detection
method also allows for ADR because the wall between
the subintima and the true lumen can be punctured
at the intended part in an exactly vertical direction
using the IVUS observation (Figure 16.25A, the first
Advantages of TD-ADR over
Stingray-ADR
Intentional ADR has been considered difficult by
IVUS-guided wiring. However, we first found that
intentional ADR is possible using the tip detection
152 PART IV Wires Technique
A. Stingray-ADR
Reentry is possible anywhere (red line and allows) except for calcied parts by TD-ADR
with
Ideal reentry point
method because an exact vertical directional puncture
at the intended part can be achieved as mentioned
above. TD-ADR is breakthrough method because the
successful guidewire passage of the CTO lesion is guaranteed when you can observe the distal lumen by IVUS.
Figure 16.26 shows the pros and cons of Stingray-ADR
and TD-ADR [10]. The standard strategy of ADR in the
world is the Stingray-ADR. But there can be problems in
visualizing the target because this technique depends on
angiographic images. For this reason, when Stingray-ADR
is performed, it often results in the creation of reentry at
the distal part, and the success rate is about 60–80% due to
the uncertain punctures. Compared with Stingray-ADR,
TD-ADR enables the puncture to be at a more proximal
part and allows a pinpoint puncture at the intended part in
a vertical direction, because both the target and the guidewire tip are clearly visible using the IVUS observation. In
addition, from 2021, Conquest Pro 12 ST (CP-12ST; Asahi
Intecc Co., Ltd.), which is a new ADR wire produced by
Dr. E. Tsuchikane at Toyohashi Heart Center, can be used
in Japan. Conquest Pro 12 ST has the pre-shape 1st-curve
of 1.3 mm, 45 degree and the four times penetration
1) Long-axis image
CTO
Intraplaque
Distal lumen
Subintima
Not a puncture in the optimal position
power of Conquest Pro 12g. Using the Conquest Pro 12
ST, it is possible to penetrate the wall between the subintimal space and the true lumen regardless of its thickness
and the true lumen, and it is even possible to penetrate the
CTO body. In other words, using TD-ADR with the
Conquest Pro 12 ST, reentry is possible anywhere except
for calcified parts. The lumen of the distal lumen just
beyond the CTO exit is usually maintained, therefore the
proximal puncture, which is an ideal puncture, is easier to
perform (Figure 16.27). However, when performing
TD-ADR, a 7Fr guiding catheter is required because both
AO-IVUS and a microcatheter are used.
Procedural details of TD-ADR
If the guidewire enters the subintimal space and is
difficult to pass through the intraplaque route, move
onto TD-ADR. The guidewire for TD-ADR should
have a high penetration force, therefore Conquest
Pro 12 ST (pre-shape of 1.3 mm, 45 degree) should
be selected, but Conquest Pro 20 g (pre-shape of 1.0
mm, 45 degree) is also possible. As for the guidewire curve, add the second curve to the pre-shape
2) Short-axis imageat the dotted line
Invisible image
Not a puncture
to the ideal point
Not a vertical
puncture
Puncture wire
B. TD-ADR
1) Long-axis image
CTO
Intraplaque
Back and forth movement of the transducer for the tip detection method
Figure 16.26 The pros and cons of Stingray-ADR and TD-ADR.
a Conquest Pro 12 ST wire.
Figure 16.27 Ideal reentry point by TD-ADR with Conquest Pro 12 ST wire.
Distal lumen
AO-IVUS
Clear image
A puncture in the optimal position
Subintima
CTO
Calc.
Calc.
Subintima
2) Short-axis image at the dotted line
An exact vertical puncture to
the ideal point
Puncture wire
Clear image
Tipand
its direction
Distal lumen
Distal lumen
Subintima
CHAPTER 16 3D Wiring Methods in CTO PCI 153
Long-axis image of uoroscopy
(1)
point
(2)
(3)
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first curve according to the IVUS information of the
vessel diameter and target size and shape. After the
puncture, the microcatheter should be advanced into
the true lumen while being shallowly punctured with
the guidewire, therefore a small diameter microcatheter such as Finecross GT (Terumo Corp.) is preferable.
This method is a technique similar to the Seldinger
technique which is echo-guided vascular puncture.
Details of the TD-ADR procedure are described
below. (Figure 16.28). Similar to stingray-ADR, TD-ADR
uses the stick and swap technique. (1) Formation of the
second curve (Figure 16.28-1): Advance the puncture
guidewire through the microcatheter and check how
it can hit the wall. Check the IVUS image and form an
additional second curve if necessary, so that the apex
of the tip can hit the wall vertically. (2) Stick (Figure
16.28-2): Puncture the wall at the intended site in an
exact vertical direction. At the time of puncture, not only
Determine which side of the IVUS to puncture
Form a second curve from the IVUS image
IVUS
CP-12ST
Subintima
the short-axis IVUS image but also the long-axis fluoroscopic image is sometimes useful because it can confirm vertical puncture on the long axis. (3) Swap (Figure
16.28-3): Once the tip has penetrated the wall, advance it
about 5 mm while keeping the apex of the tip inside the
distal lumen. Then, under IVUS observation, the microcatheter is advanced into the lumen and the tip of the
microcatheter can be detected by the acoustic shadow.
The puncture guidewire is changed to a soft guidewire.
From 2021 to 2022, TD-ADR was performed in 22 cases
in our hospital, and TD-ADR was successful in all cases.
Representative case of TD-ADR [10]
A man in his 70s suffered from effort angina pectoris due
to CTO lesions in the LCX. PCI was performed on the
CTO lesion at another hospital. During AWE, a guidewire seemed to enter the subintimal space angiographically and could not be passed through the CTO lesion.
Vertical puncture at the intended
CP-12ST
Intraplaque
Distal lumen
Intraplaque
Short-axis image of IVUS
Advance the guidewire about
5mmwhile keeping theapexof
the tip insidethe distal lumen.
CP-12ST
Intraplaque
CP-12ST
Intraplaque
CP-12ST
IVUS
Fix the IVUS transducer just beyond the puncture site, and visually
conrm that the microcatheter is inserted into the lumen.
Shaft of
CP-12ST
Microcatheter
Intraplaque
Acoustic shadow
Intraplaque
Figure 16.28 Procedural details of TD-ADR.
154 PART IV Wires Technique
The patient was admitted to our hospital for a retry
procedure for the CTO lesion. We planned to perform
only the antegrade approach because there were no
interventional retrograde channels. The procedure was
performed from the femoral approach with an 8-Fr
guiding catheter. An XT-R wire supported by a Finecross
GT microcatheter (Terumo Corp.) seemed to enter the
subintimal space angiographically, which was confirmed
by AO-IVUS (Figure 16.29A, 16.29B). Then, the
AO-IVUS-based 3D wiring was performed for intraplaque tracking (Figure 16.29B), but the guidewire could
not be advanced because of a huge calcified wall at the
transition site. Although the true lumen beyond the
CTO exit was not clearly visible angiographically, we
moved onto Stingray-ADR using an angiographic observation (Figure 16.29C). Using Conquest (Confianza)20g (Asahi Intecc) and XT-R wires, five attempts of the
A
Entrance
of CTO
D
Tip of Conanza 20g
B
Tip of Conanza 20g
E
stick-and-swap technique were performed, but the
guidewire could not be led into the true lumen under the
angiographic observation (Figure 16.29D).
IVUS observation revealed a distal true lumen in
which the inner lumen was maintained 5 mm beyond
the CTO exit (Figure 16.30A). We decided to perform
TD-ADR using the AO-IVUS observation. The
Conquest (Confianza)-20g supported by the Finecross
was advanced at the site where we attempted reentry
(Figure 16.29E). The tip detection method allowed
the tip of the Confianza-20g to puncture the wall between the subintima and the true lumen in an exactly
vertical direction (Figure 16.30B–16.30E) (online
video in reference 10), resulting in successful reentry
(Figure 16.30F). The CTO lesion was dilated with one
drug-eluting stent, and normal antegrade blood flow
was achieved (Figure 16.29F).
C
IVUS
transducer
st
1
- guidewire
F
Distal true lumen
Stingray balloon
Tip of Conanza 20g
Figure 16.29 Angiographic images in PCI for the CTO lesion in the LCX.
A
True lumen
D
Tip and
its direction
Subintima
B
Tipand
its direction
E
Tip and
its direction
IVUS
transducer
Stent
C
Tipand
its direction
F
Guidewire
shaft
Figure 16.30 TD-ADR: Successful reentry using the tip detection method.
Conclusion
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We believe that the 3D wiring methods will greatly
contribute to the standardization of CTO PCI procedures. We hope that this method will be widely spread
and that CTO-specific VUS such as AO-IVUS will be
available all over the world.
References
1 Okamura A, Iwakura K, Fujii K. ViewIT improves intravas-
cular ultrasound-guided wiring in coronary intervention of
chronic total occlusion. Catheter Cardiovasc Interv 2010; 75:
1062–1066.
Okamura A, Iwakura K, Date M et al. Navifocus WR is the
2
promising intravascular ultrasound for navigating the guidewire
into true lumen during the coronary intervention for chronic
total occlusion. Cardiovasc Interv Ther 2014; 29: 181–186.
3
Okamura A, Iwakura K, Nagai H et al. Chronic total occlu-
sion treated with coronary intervention by three-dimensional
guidewire manipulation: an experimental study and clinical
experience. Cardiovasc Interv Ther 2016; 31: 238–244.
4
Tanaka T, Okamura A, Iwakura K et al. Efficacy and feasi-
bility of the three-dimensional wiring technique for chronic
total occlusion percutaneous coronary intervention: first
report of outcomes of the three-dimensional wiring technique. J Am Coll Cardiol Intv 2019; 12: 545–555.
Okamura A, Iwakura K, Iwamoto M et al. Tip detection
5
method using the new IVUS facilitates the 3-dimensional
wiring technique for CTO intervention. J Am Coll Cardiol
Intv 2020; 13: 74–82.
CHAPTER 16 3D Wiring Methods in CTO PCI 155
6
Suzuki S, Okamura A, Iwamoto M et al. New CTO-
specific IVUS: AnteOwl success in previously failed CTO
case treated with navifocus IVUS. J Am Coll Cardiol Case
Rep 2020; 2: 961–965.
7
Tanaka K, Okamura A, Iwakura K et al. Visualization
of the accurate guidewire tip movement during the tip
detection method in the new IVUS-based 3D wiring
for CTO intervention. J Am Coll Cardiol Intv 2020; 13:
e67–e68.
Suzuki S, Okamura A, Iwakura K et al. Initial outcomes
8
of AnteOwl IVUS-based 3D wiring using the tip detection method for CTO intervention. J Am Coll Cardiol
Intv 2021; 14: 812–814.
9
Okamura A, Nagai H, Tanaka K et al. Possibility of
AnteOwl IVUS-based antegrade dissection and reentry
using the tip detection method for CTO-PCI. Cardiovasc
Interv Ther. 2022 Feb 15. [E-pub ahead of print], doi:
10.1007/s12928-022-00846-2.
Suzuki S, Okamura A, Nagai H et al. Tip detection-ante-
10
grade dissection and reentry using intravascular ultrasound in chronic total occlusion intervention: first human
case report. Eur Heart J Case Rep 2022; 6: 1–5.
11
Okamura A, Nagai H, Tanaka K, Suzuki S, Watanabe H,
Iwakura K. A case and video presentation using rotational ETOSS of intentional route tracing by angiography-based 3D wiring in CTO-PCI. Cardiovasc Interv
Ther 2022 May 3. doi: 10.1007/s12928-022-00861-3.
12
Michael TT, Papayannis AC, Banerjee S, Brilakis ES.
Subintimal dissection/reentry strategies in coronary
chronic total occlusion interventions. Circ Cardiovasc
Interv 2012; 5: 729–738.
17
CHAPTER 17
Antegrade Fenestration
and Re-Entry
An Alternative Approach to Antegrade Dissection and
Re-Entry
Lorenzo Azzalini1,* & Mauro Carlino
1
Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA, USA
2
Division of Interventional Cardiology, Cardio-Thoracic-Vascular Department, San Raffaele Scientific
Institute, Milan, Italy
* Corresponding author
Introduction
When, two decades ago, extraplaque tracking started
to be used as an intentional approach to achieve true
lumen re-entry, a disruptive change in the “philosophical” approach to chronic total occlusion (CTO) percutaneous coronary intervention (PCI) had occurred. In
fact, guidewire entry into the extraplaque space had
historically been considered an undesired event, often
heralding the failure of recanalization attempts. When
Antonio Colombo introduced subintimal tracking
and re-entry (STAR) in 2005, the antegrade dissection/re-entry (ADR) approach was born [1]. ADR
techniques allowed tackling, for the first time, more
complex occlusions, where maintaining an intraplaque
track along the occlusion was unlikely to be successful
and associated with the risk of perforation. However,
after the initial encouraging results [2], it soon became
clear that extensive dissection planes due to unpredictable re-entry, with subsequent side branch loss and
poor runoff, were linked to suboptimal patency rates
on mid-term follow-up [3]. Further modifications of
this first-generation ADR approach (mini-STAR, contrast-guided STAR, and limited antegrade subintimal
tracking [LAST]) were unable to lead to a significant
improvement in patency rates, due to the same challenges in controlling the exact re-entry site encountered
by STAR, as well as lack of reproducibility [1, 3–5].
2
A radical shift in this field was represented by the
introduction of a device-based ADR, namely the
Stingray system (Boston Scientific, Marlborough,
MA). After reaching the distal “landing zone” (i.e.,
where re-entry is to be attempted, distal to the distal
cap) with either a wire-based approach (e.g., knuckle)
or a dedicated device (CrossBoss, Boston Scientific),
the Stingray balloon is advanced. Re-entry is then
achieved by puncturing with a high-tipload wire from
the extraplaque space into the true lumen (see
Chapter15). Integration of Stingray-based ADR into
the hybrid algorithm has led to improved procedural
efficiency and success rates of CTO PCI, with better
longer-term outcomes compared to earlier wire-based
approaches [3, 6–8].
Nevertheless, adoption of Stingray-based ADR has
been limited by costs, need for proctoring training
(steep learning curve), and a still non-optimal success
rates (failure is most frequently due to compressive
hematoma and/or inability to puncture through fibrocalcified tissue). Even in proctors’ hands, Stingray-based
ADR success rates are not ideal (81%) [7]. Due to all the
aforementioned limitations, Stingray-based ADR represents one-third to a half of CTO PCI procedures [6, 7] in
“hybrid” communities, and is negligible in others [9, 10].
For these reasons, research into novel ADR
approaches has been fervent.
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.
156
CHAPTER 17 Antegrade Fenestration and Re-entry 157
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Antegrade fenestration and re-entry
(AFR): Pathophysiological bases and
development of a new approach to
ADR
Cutting balloon angioplasty has classically been used
to relieve occlusive subintimal hematomas (for example, in the context of spontaneous coronary artery dissection) and recanalize the vessel (Figure 17.1) [11].
The cutting action of the blades create fenestrations
between the false and true lumen, thus putting into
communication the two spaces and evacuating the
hematoma into the distal true lumen.
Our hypothesis that a similar approach could be
utilized to recanalize CTOs, sparked the idea for the
development of antegrade fenestration and re-entry
(AFR). Specifically, when an antegrade wire has
reached an extraplaque location beyond the distal cap,
a balloon is advanced on such wire, with the goal of
creating fenestrations between the extraplaque space
and the distal true lumen, which can subsequently be
engaged by a second wire to achieve re-entry. At variance with the aforementioned approach to treat occlusive hematomas in spontaneous coronary artery
dissection, where the wire is located in the true lumen,
in this CTO scenario the wire would be in the extraplaque space.
The same concept had already been applied in the
context of reverse controlled antegrade and retrograde subintimal tracking (reverse CART), where the
Figure 17.1 Occlusive hematoma due to spontaneous coronary artery dissection, which was recanalized with cutting
balloon angioplasty. Coronary angiogram and optical coherence tomography (OCT) images of the left anterior
descending (LAD) artery after cutting balloon angioplasty. Still frame of the coronary angiogram after fenestration of the
intramural hematoma (double lumen, magnified view). OCT showing effective relieving of the compressive intramural
hematoma in the mid (B) and distal (C) LAD. Abbreviations: TL, true lumen. Arrows, sites of cutting balloon angioplasty.
Reproduced with permission from [11].
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