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208 PART IV Wires Technique
Figure 23.5 Utility of CCTA and IVUS to identify an
ambiguous proximal cap. Panel A shows proximal left
anterior descending artery (LAD) chronic total occlusion
with ambiguous proximal cap. The red arrow points to the
distal cap which is visualized from septal collaterals from
the right coronary artery. Panel B shows caudal view with
ambiguous proximal cap and ostial LAD occlusion. Panel C
shows an IVUS catheter in a diagonal branch (red arrow)
which is used to identify the proximal cap of the CTO.
Panel D shows a heavy tip load penetration wire engaging
the proximal LAD CTO cap identified on IVUS. Panel E
shows successful wiring of the LAD following IVUS guided
cap puncture (red arrows). Panel F and G shows CCTA
views of the LAD occlusion with heavy calcification and its
relation to the large diagonal branch. Panel H shows IVUS
in the diagonal branch with the ostial LAD cap outlined in
the red circle. Panel I shows final view after successful LAD
CTO recanalization using CCTA and IVUS to overcome
proximal cap ambiguity.
Figure 23.6 Move the cap techniques. This figure shows the various move the cap techniques that can be used to
overcome an ambiguous proximal CTO cap.
repeatedly (ideally in diseased segment) to create a dissection in the vessel proximal to the cap. The microcatheter is trapped next to the inflated balloon in the
mid segment and then the polymer jacketed wire is
pushed into the extraplaque space and knuckled.
The presence of a side branch at the site of proximal
occlusion can be used to perform side-BASE tech-
nique (Figure 23.7) [16]. First, a 1:1 sized NC balloon
inflated in the proximal vessel to create a proximal dissection and then removed. A microcatheter on a second wire is advanced to the proximal cap. Then, a
balloon sized 1:1 with the side branch is placed partly
in the side branch and inflated to nominal pressure.
This side branch balloon acts as an anchor and deflect
CHAPTER 23 How to Handle Subintimal Dissections 209
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Figure 23.7 Side BASE technique. This figure (panels A-E) outline steps of performing a side BASE technique.
the polymer jacketed wire away from the side branch.
With the side branch balloon inflated, the polymer
jacketed wire in the microcatheter is pushed with the
premise that the balloon deflects the looped wire
beyond the proximal cap within the extraplaque space.
Another option to resolve ambiguity involves creating a hydraulic microdissection (“Carlino” technique)
in the extraplaque space by injecting small volume contrast (<1mL) through a microcatheter (Figure 23.6) [8,
17]. This leads to a tubular dissection in the extraplaque
space which can help outline the vessel course.
Crossing the CTO body
Once the knuckled polymer jacketed wire has entered
the extraplaque space, it can be advanced around the
CTO body in the extraplaque space to the distal re-entry
zone. It’s important to minimize the size of the extraplaque space to prevent excessive hematoma formation
and subsequent compression of the distal true lumen.
Therefore, polymer jacketed wires that form a small
loop should be the initial wires of choice (Table 23.1).
Potential challenges to crossing the CTO body include
inability to advance the knuckled guide wired due to
calcification and/or tortuosity and guidewire entering a
side branch.
Troubleshooting getting there:
Navigating the extraplaque space
Increasing guide catheter support is one way to overcome difficulty in advancing the knuckled guide wire
through the CTO body due to calcification or tortuosity. This can be done by deep seating or using supportive guide catheters (Amplatz or 3D right for RCA and
EBU or XBU for LCA), guide extension catheters or
Trapliners, and side branch anchor balloon. Hydraulic
microdissection or Carlino technique as described
earlier can be used to outline the vessel course in the
setting of tortuosity and also soften the extraplaque
space by hydraulic fracking. If the knuckled guidewire
enters a side branch such as acute marginal branches
of the right coronary artery (RCA), it can often be difficult to redirect the knuckled wire. To overcome this,
a stiffer polymer jacketed guidewires such as Pilot 200
(Table 23.1) which form larger knuckles should be
used as they are less likely to enter the side branches.
Once the guidewire with the larger knuckle is past the
side branch, it should be exchanged for a guidewire
with smaller loop to keep the extraplaque space small.
High tip load guidewires can be used to direct away
from the side branch as an alternative. Once the CTO
body is traversed in the extraplaque space, device-
210 PART IV Wires Technique
based reentry techniques can be attempted distal to
the CTO body.
Antegrade re-entry techniques
Antegrade re-entry techniques can broadly be categorized into wire-based or device-based techniques.
Wire-based re-entry techniques include subintimal
tracking and reentry (STAR), modified or contrastguided STAR, mini-STAR and limited antegrade
subintimal tracking (LAST) [18, 19].
The STAR technique was first reported by Colombo
et al. in 2005 [20]. It involves blunt dissection with a
polymer jacketed knuckled wire in the extraplaque
space until it spontaneously re-enters the distal true
lumen with re-entry most often occurring at branch
points or sites of tortuosity (Figure 23.8A). In the
31-patient series reported by Colombo at al., the procedure success rate was 97%, however on follow-up
angiography around 5 months, 52% of the patients has
restenosis and underwent repeat target vessel revascularization (TVR). It’s important to note that the use of
bare metal stents (BMS) was around 37% in this
series. In another retrospective analysis of 119 patients
who underwent successful CTO PCI with STAR technique and treated with drug eluting stents (DES),
Carlino at al. looked at predictors of restenosis.
During a median angiographic follow-up of 8.5
months, the target vessel restenosis rate was 63%.
Multivariable analysis with model including 2nd generation drug-eluting stent (DES), stent length and history of diabetes showed that TIMI flow <3 was the
only independent predictor of restenosis and reocclusion (HR 0.48, p=0.027 and HR 0.24, p=0.008) [21].
The modified STAR or contrast-guided STAR technique was described by Carlino et al. in 2008 [22]. This
technique involves penetrating the proximal cap with a
sharp wire and advancing the tip of the microcatheter
into the cap followed by intraplaque contrast injection
(1–2mL) through the microcatheter to cause a hydraulic tubular dissection (Figure 23.8B). This tubular dissection would then be used to facilitate distal true
lumen re-entry with either further contrast injections
to fenestrate into the distal true lumen or a polymer
jacketed knuckle wire. In a series of 68 patients with
CTOs, angiographic success was achieved in 81% of
patients with 71% achieving complete recanalization.
A procedural complication occurred in 10% of cases.
Over a median follow-up of seven months, TLR rate
was 30% in patients treated with DES and 50% of
patients treated with BMS [22]. In another retrospective series of 355 patients, 74 patients that underwent
contrast guided STAR technique had a significantly
higher restenosis rate of 54% compared to 30% in
patients undergoing conventional antegrade CTO
recanalization at a median follow-up of 2.1 years. Stent
length was the only significant independent predictor
of restenosis (HR 1.017, p<0.0001) [23]. Contrastguided STAR technique is associated with higher procedural complication rates and poor long-term results
likely due to the need for longer stent length.
The mini-STAR technique is another modification
of the STAR technique which utilizes low tip load polymer jacketed wires such as Fielder XT or Fielder FC
(Asahi Intecc) shaped with a small primary bend (40–
50 degrees) at the distal end (1–2 mm proximal to the
tip) and a secondary bend (15–20 degrees) 3 to 5 mm
proximal to the tip [19, 24]. An initial attempt is made
to cross the CTO however if wire advancement does
not lead to distal true lumen crossing, the wire is
manipulated to form a J loop which is then advanced to
penetrate the extraplaque space. The knuckled wire is
then advanced forcefully in an attempt to re-enter the
distal true lumen as close to the distal cap as possible to
limit the length of the dissection plane (Figure 23.8C).
This technique relies on the properties of the low tip
Figure 23.8 Wire Based Re-entry Techniques. Panel A
shows traditional STAR technique with distal re-entry at
the bifurcation. Panel B shows contrast guided STAR
technique. Panel C shows a mini-STAR technique with
reentry close to the distal cap.
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load polymer jacketed wires to form small knuckle as
close to the distal cap as possible for early re-entry and
minimize length of extraplaque tracking. Mini-STAR
technique was associated with a procedural success rate
of 98% compared to conventional techniques for bailout without a significant difference in periprocedural
complications [24]. At 2-year follow-up, major adverse
cardiac events (MACE)-free survival was 89% and TLR
rate of 6.5% in patients that underwent mini-STAR
technique as a bailout strategy [25]. Angiographic follow-up in 72% of the patients showed a CTO restenosis
rate of 25% and a reocclusion rate of 12.5% [25]. Final
TIMI flow <grade 3 was an independent predictor of
MACE (HR 5.9, P=0.013) [25]. CTO stent length (OR
0.96, P=0.017) and final TIMI flow < grade 3 (OR 5.41,
P=0.043) were independent predictors of reocclusion
[25]. CTO stent length (OR 0.97, P=0.027) and firstgeneration DES (P=0.022) were independent predictors of restenosis [25].
The limited antegrade subintimal tracking (LAST)
technique is another variation of the STAR technique.
In this technique, a knuckled wire is used to blunt dissect through the extraplaque space past the distal cap
and then targeted re-entry is attempted using a high
tip load penetration wire with an acute distal bend
and microcatheter for support. This technique relies
on feeling resistance and then advancing the wire into
the true lumen. This technique is less predictable and
not commonly used in contemporary CTO PCI [19].
Overall, these wire-based ADR techniques are
uncontrolled, unpredictable, and associated with
higher risk of side branch loss and target vessel
revascularization rates [20, 23]. Furthermore, these
techniques have lower procedural success rates,
higher MACE rates and less improvement in myocardial blood flow compared to device-based reentry techniques [26, 27]. Therefore, wire-based
techniques have fallen out of favor and used as a bailout if other techniques fail for successful CTO revascularization [19].
Dedicated device-based re-entry
The Stingray balloon (Bridgeport Medical/Boston
Scientific, Minnesota) is a dedicated device designed
to facilitate controlled re-entry with reported success
rates as high as 87% [28, 29]. It is a flat shaped overthe-wire balloon, 2.5 millimeters in diameter and 10
millimeters in length with two exit ports (180 degrees
opposite each other) for selective guidewire re-entry
and a third over-the-wire port (Figure 23.9). It is
6-French guide compatible with a proximal outer
shaft diameter of 3.2Fr and distal outer diameter of
2.7 Fr.
Figure 23.9 Stingray LP balloon and re-entry. Panel A: The
stingray LP is a flat shaped over-the-wire balloon, 2.5
millimeters in diameter and 10 millimeters in length with
two exit ports (180 degrees opposite each other) for
selective guidewire re-entry and a third over-the-wire
port. Panel B and C show position of the Stingray LP
beyond the distal cap with one port facing the true lumen
which can be selected by a stiff guidewire to perform
reentry.
212 PART IV Wires Technique
After crossing the CTO body through the extraplaque space, an optimal landing zone for re-entry is
selected. In general, a good landing zone for re-entry
should have no or minimal calcification, plaque burden and extraplaque hematoma, large lumen diameter
(>2.5 mm), lack of tortuosity, absence of a large side
branch and good retrograde filling. Meticulous preparation of the Stingray balloon is important to allow
visualization of the wire exit direction. Ideally 7Fr or
larger guide catheters with a 7Fr Trapliner facilitates
efficient equipment exchange and support to deliver
the Stingray balloon. Guidewire position during
Stingray balloon delivery is important as forward
movement of the guidewire can result in enlargement
of the extraplaque hematoma. Supportive non-polymer coated hydrophobic wire such as MIRACLEbros
12 (Asahi Intacc) or the original knuckled wire can
help delivery the Stingray balloon to the reentry zone.
If there is difficulty in delivering the Stingray balloon
to the reentry zone, a microcatheter can be used to
create a channel, a small balloon (1.0–15 mm) to predilate the track and increase guide catheter support.
Once at the reentry zone, the balloon is inflated to
2–4 atm and the guidewire is removed from the central port. At this point, a syringe can be attached to the
central port with negative pressure to aspirate any
residual hematoma prior to attempted reentry. The
orientation of the true lumen in relation to the exit
ports of Stingray balloon should be identified by
rotating the fluoroscopy C-arm until the Stingray balloon is visible as a single line (wings overlapped) and
not as a double line (wings en face). Once the appropriate angiographic orientation is obtained where the
balloon is visible with wings overlapped, retrograde
contrast injection is done to identify the direction of
the true lumen to select the appropriate exit port. One
port faces the adventitia and the other faces the true
lumen (Figure 23.9).
The re-entry is typically attempted with high tip
load penetrating guidewires (Astato 20, Confianza
Pro 12, Hornet 14, Stingray wire, or Gaia Next 3). A
30–45-degree bend 1 mm from the tip is made on the
re-entry guidewire. The re-entry guidewire is
advanced until the wire tip exits the port facing the
true lumen (Figure 23.9). Then a “stick and roll”
motion is applied to the wire as it exits the port.
Contralateral injection is then used to confirm wire
position in the true lumen. If the guidewire is in the
true lumen, it is advanced further into the true lumen
distally (“Stick and drive” technique). Alternatively, a
“stick and swap” technique can be used in the presence of a diseased or tortuous distal landing zone. A
high tip load penetrating wire is used to create multiple fenestrations or “sticks” and then exchanged for a
stiff polymer-jacketed wire (Gladius Mongo or Pilot
200). After successful distal re-entry, the Stingray balloon is removed and microcatheter is passed distally
to exchange to a workhorse wire.
The ReCross device is a newer re-entry device
which is a dual lumen microcatheter with two overthe-wire lumens with exit ports offset by 180 degrees
similar to the Stingray balloon (Figure 23.10). It also
has a removable stylet for increased pushability to
facilitate delivery to the re-entry zone. One of the two
lumens can be used to apply suction to allow aspiration of hematoma to decompress the extraplaque
space [30]. There is limited experience with this
device as a dedicated re-entry tool and further data
are needed.
Antegrade fenestration and re-entry
(AFR)
AFR is a non-targeted re-entry technique which
involves extraplaque ballooning (sized 1:1 with the
vessel) at the distal cap to create fenestrations between
Figure 23.10 Recross device. This figure shows a Recross
dual lumen microcatheter with two over-the-wire lumens
with exit ports offset by 180 degrees similar to the
Stingray balloon. It also has a removable stylet for
increased pushability to facilitate delivery to the re-entry
zone.
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the extraplaque space and the distal true lumen [2,
31]. A second polymer jacketed wire with low tip load
(Fielder, Sion black, Bandit, or Fighter) is positioned
in the same extraplaque space and as the balloon
deflates, the wire is advanced through the fenestrations into the distal true lumen. The technique is
highlighted in a single center case series of six patients
(Figure 23.11) [31]. Larger studies are needed to
establish reproducibility of this technique for re-entry
as well as long term outcomes.
Troubleshooting getting in
Hematoma formation in the extraplaque space can
compress the distal true lumen and lead to loss of visualization of the distal vessel making re-entry challenging (Figure 23.12). The Sub-intimal TRAnscatheter
Withdrawal (STRAW) technique can be a potential
solution. A syringe with negative pressure can be
placed on the over-the-wire port of the Stingray catheter once it’s delivered to the re-entry zone to aspirate
Figure 23.11 Antegrade fenestration and re-entry (AFR). This figure outlines the steps of the AFR technique.
214 PART IV Wires Technique
Figure 23.12 IVUS of Extraplaque hematoma. This figure
shows an IVUS image of a large extraplaque hematoma
and decompress the extraplaque space. Alternatively,
an over-the-wire balloon can be advanced into the vessel over a second guidewire sized 1:1 with the vessel
and placed proximal to the proximal cap. It is then
inflated, and a syringe is attached to the proximal port
of the balloon for to block inflow and allow aspiration
of blood from the extraplaque space [8, 32]. If distal
vessel visualization is poor or lost, blind stick through
both Stingray exit ports can be performed followed by
swapping to a polymer-jacketed wire. “Bob-sledding”
is another technique that can be employed if re-entry is
unsuccessful at the initial attempt [8]. The Stingray
balloon is deflated and advanced over a stiff wire
placed inside of the end exit port of the Stingray balloon to allow the balloon to be positioned into a more
favorable location within the target vessel to attempt
another re-entry.
In contemporary practice, STAR technique has
reemerged as an effective bailout strategy when other
approaches have failed and can be used as an investment procedure if ADR is unsuccessful. Current iteration of the STAR technique to minimize dissection
length, ensuring good distal outflow and deferred
stenting appear to have improved outcomes however,
long-term follow up data are needed [18].
Safety and efficacy and outcomes of
ADR
ADR plays an important role in hybrid approach to
contemporary CTO PCI and is used in approximately
20–30% of CTO PCI cases in large registries with success rates around 65% [3, 4, 33]. The need for ADR
and retrograde approach increases with higher lesion
complexity assessed by the Japanese-CTO score [3].
However, compared to antegrade approaches, retrograde approach is associated with higher complications rates, therefore ADR is an important technique
for revascularization of higher complexity CTOs [3].
(red outline) compressing the true lumen (yellow
outline).
Concerns regarding durability of ADR were raised
due to the high target vessel revascularization rates
that were observed following the early experience
with STAR. Imaging studies have consistently shown
that extraplaque tracking is not associated with target
vessel failure at 1 year [34, 35]. The CONSISTENT
CTO (Conventional Antegrade Versus Sub-Intimal
Synergy Stenting in Chronic Total Occlusions) study
assessed procedural durability of dissection and reentry techniques in an elegant study. In this study of
231 patients, CTO PCI success rate was 91%. In the
subgroup of patients that required dissection and reentry technique (DART), longer stent length was
required (97 mm versus 75 mm), however this was
not associated with significant increase in TVR or
MACE at 12 and 24 months. The presence of diabetes
was the strongest predictor of MACE and TVR. In
this largest post PCI optical coherence tomographic
(OCT) follow up, there was no significant difference
in vessel healing at 12 months between DART and
intimal wiring groups. Interestingly, in 15.8% of cases,
there was discordance between operator presumed
and core laboratory IVUS analysis of intra versus
extraplaque equipment passage. Intravascular imaging is important and can provide valuable information
on wire tracking which can have implications for stent
strategy and prediction of closure of side branches [2].
Studies have shown that operator-reported tracking is
imprecise and extraplaque tracking can be identified
in up to 28% of cases of antegrade wiring or retrograde wiring cases despite attempted intra plaque
crossing [2, 36].
Future directions
ADR is an important but unpredictable technique for
CTO PCI. A common problem which arises during
ADR is expansion of the extraplaque hematoma and
subsequent inability to maintain visualization and
CHAPTER 23 How to Handle Subintimal Dissections 215
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close proximity to the true lumen after initiating a
dissection. The currently available reentry device
(Stingray LP balloon) is limited by poor trackability
and deliverability to the reentry site and limited exit
ports for aspiration of extraplaque hematoma. A
newer reentry catheter with 6 ports (2 ports offset
180 degrees from each other at 120 degree intervals–
therefore an exit port is present every 60 degrees on
the circumference of the catheter) overcomes the
limitations of the currently available reentry device
(Figure 23.13). This 3F catheter allows simultaneous
continuous aspiration of extraplaque hematoma
while and performing reentry using one of the 6
ports. Figure 23.14 shows a case example of loss of
distal vessel visualization due to hematoma compressing true lumen and subsequent return of visualization after aspiration of hematoma.
Conclusion
Advances in techniques and equipment have led to
increased CTO PCI success rates without an increase
in complication rates in recent years. Dissection and
re-entry techniques utilizing the extraplaque space
can be helpful in overcoming anatomic challenges of
higher complexity CTO cases. Contemporary ADR
techniques have an important role in the hybrid
approach to CTO PCI and associated with durable
Figure 23.13 Novel reentry microcatheter. Figure on the
left shows the distal end of a novel reentry microcatheter
with 6 exit ports marked by “X” and “O” (2 ports offset
180 degrees from each other at 120 degree intervals–
Figure 23.14 Aspiration of extraplaque hematoma using a
novel reentry catheter. Panel A shows angiography of the
right coronary artery (RCA) with visualization of the distal
vessel on dual angiography. Panel B shows loss of
therefore an exit port is present every 60 degrees on the
circumference of the catheter). Figure on the right shows
the appearance of the catheter under fluoroscopy.
visualization after antegrade dissection. Panel C shows
return of distal vessel visualization after aspiration of
extraplaque hematoma through the new reentry
microcatheter.
216 PART IV Wires Technique
short and long term outcomes. Novel dedicated ADR
devices are on the horizon to help overcome some of
the major challenges of ADR technique.
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