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Tony Das MD FACCCardiovascular Education Group
Complex Tibial CTO Techniques
Tony Das MD FACC Director, Peripheral Interventions
Dallas, Texas
Tony Das MD FACCCardiovascular Education Group
Das Disclosures 2010 Abbott Vascular Research/Education Angioslide Consultant Bard Vascular Education Boston Scientific Research Cordis Endovascular
Consultant/Education/Research CSI Consultant/Equity/Education WL Gore Education IDEV Consultant/Equity/Education Spectranetics Consultant/Education VIVA Board member/Grant support
Educational grafts consist of PVD and Carotid proctorship
support
Tony Das MD FACCCardiovascular Education Group
Evaluating Tibial CTO’s
Best case-distal visualization
Tony Das MD FACCCardiovascular Education Group
How are Infrapopliteal CTO’s different than SFA occlusions?
Often calcified Unable to reliably use subintimal
technique Re-entry options are limited More emphasis on true lumen crossing Angled takeoffs of AT and PT Distal vessels often not well seen
Tony Das MD FACCCardiovascular Education GroupDirect Local Imaging
RIM Catheter
Support or Glidecatheter
Crossover sheath
65-90 cm
Direct visualization to the foot
Tony Das MD FACCCardiovascular Education Group
Guidewires for BTK CTO
Persuader 3,6,9 (Medtronic) Miracle Bros 4.5, 6, 9 (Abbott) Confianza wire (Abbott) Runthough wire (Terumo)____________________________
_ V-18 control wire (BSC) Glidewire gold (Terumo)
Tony Das MD FACCCardiovascular Education Group
Complex Tibial CTO Techniques
Guidewires and support catheters0.014in coronary CTO wires/ Quickcross
Re-entry devices Differential dissection CTO devices for BTK PTA/Cryoplasty/Laser/Atherectomy/Stent Tibial retrograde options
Tony Das MD FACCCardiovascular Education Group
Leipzig Registry data. A. Schmidt et al. Catheter Cardiovasc Interv 2010Low patency rates with PTA alone: Restenosis 68.8% @3 mo
Tibial CTO with PTA only
Tony Das MD FACCCardiovascular Education Group
Drug Eluting Balloon BTKLeipzig Trial Results
InPact Amphirion Paclitaxel eluting balloon
104 patients/ 109 limbs
Mean lesion length: 173 +/- 87 mm
DEB POBA0
10
20
30
40
50
60
70
Restenosis (3 mo) angio
Restenosis (3 mo) angio
Tony Das MD FACCCardiovascular Education Group
PTA with Cryoplasty
Tony Das MD FACCCardiovascular Education Group
CLI and Cryoplasty The BTK CHILL Trial
was a prospective, multi-center registry
N= 111 patients with CLI treated with cryoplasty. 67% Diabetics 35% Occlusions
Procedural success was 97%.
Limb salvage at 6-months was 93%.
Das T, et al. .J Endovasc Ther. 2007 Dec;14(6):753-62.
93 97
0
20
40
60
80
100
6 months
Limb Salvage Procedural Success Bypass
Tony Das MD FACCCardiovascular Education Group
Laser for BTK CTO
Tony Das MD FACCCardiovascular Education Group
CLI and Laser Atherectomy The LACI Trial was a
prospective, multi-center registry of laser assisted angioplasty
N= 145 CLI patients . Poor surgical candidates 66% Diabetics 92% Occlusions
Procedural success was 86%.
Limb salvage at 6 months was 92%.
Laird, Zeller, Gray, et al, J Endovasc Ther 2006
92
86
82
84
86
88
90
92
6 Months
Limb Salvage Procedural Success
Tony Das MD FACCCardiovascular Education Group
BTK DES
Tony Das MD FACCCardiovascular Education Group
BTK Cypher DES 6 month DataAuthor R N TLR 1 Endpoint
ScheinertEuroInterv2006;2:169-174
Y 60 0 vs 23% 0 vs 56%Restenosis
SiablisJ Endovasc Ther2005;12:685-95
N 58 100%Limb
Salvage
4 vs 55%Restenosis
BosiersJ Cardiov Surg. 2006 Apr;47(2):171-6
N 18 94% Limb Salvage
0.38 Late Lumen Loss 0% Restenosis
ComeauEuroPCR 2006
N 30 100% Limb Salvage
97% 1 Patency
Tony Das MD FACCCardiovascular Education Group
ACHILLES Study- Multicenter randomized Cypher BTK to PTA
PTA Cypher05
101520253035404550
Restenosis
Restenosis
Average Lesion Length:
27mm+/- 20mm
Adapted from LINC 2011 presentation
Tony Das MD FACCCardiovascular Education Group
BTK CTO and Atherectomy
Tony Das MD FACCCardiovascular Education Group
Saline infusion port
15 cm travel
Diamondback 360˚ Orbital Atherectomy System
Tony Das MD FACCCardiovascular Education Group
Unique Mechanism of Action Centrifugal Force
2.0 mm crown at 80k RPMs
CF=mass*rotational speed2
radius of the orbit
2.0 mm crown at 200k RPMs
Tony Das MD FACCCardiovascular Education Group
Tibial Frontrunner Technique
Tony Das MD FACCCardiovascular Education Group
Tony Das MD FACCCardiovascular Education Group
Tony Das MD FACCCardiovascular Education Group
BTK New CTO Devices
65 y/o M with CAD, DM, non healing ulcer R. LE for 4 months (lateral 4th and 5th toes)
ABI: 0.3R and 0.7L at rest Referred for angiography CTO SFA, Popliteal and Tibial
Tony Das MD FACCCardiovascular Education Group
Peroneal artery occlusion
Tony Das MD FACCCardiovascular Education Group
Uncrossable with Guidewire
Tony Das MD FACCCardiovascular Education Group
The CROSSER™ System
Generator Converts AC power into high
frequency current Piezoelectric crystals within the
Transducer convert high frequency current into vibrational energy
Foot Switch activates System
CROSSER Catheter Nitinol core wire transmits mechanical
vibration to the metal tip of the Catheter at 20,000 cycles/second 20 micron amplitude (stroke depth)
Tony Das MD FACCCardiovascular Education Group
PTA and Final Result
Tony Das MD FACCCardiovascular Education Group
Occluded Tibial Vessel Access Technique
Tony Das MD FACCCardiovascular Education Group
Diamondback 1.5mm Classic
Tony Das MD FACCCardiovascular Education Group
Repeat Angiogram (9/10) 6mo
Tony Das MD FACCCardiovascular Education Group
Direct Access to DP at foot
Tony Das MD FACCCardiovascular Education Group
Micropuncture Access
Tony Das MD FACCCardiovascular Education Group
Tony Das MD FACCCardiovascular Education Group
Retrograde Recanalization
Tony Das MD FACCCardiovascular Education Group
Retrograde PTA from foot
Tony Das MD FACCCardiovascular Education Group
Final Result
Tony Das MD FACCCardiovascular Education Group
BTK Re-entry TechniqueTibial occlusion with ulcer
78 year old M w/ history of Occluded Fem-pop with non-healing ulcer
No obvious direct runoff vessel to the foot
Ulcer on 3rd and 4th toes ABI of 0.3 and toe pressure of 30 mmHg
Tony Das MD FACCCardiovascular Education Group
Tony Das, MD
Initial Angiogram- Failed Graft
Tony Das MD FACCCardiovascular Education Group
Trapped wire in subintimal space BTK
What to do next?A. Continue subintimal tractB. Consider changing to different
wireC. Considering other devices
1. Frontrunner2. Outback3. Crosser4. Other?
D. Abort CaseE. PTA SFA/popliteal
Tony Das MD FACCCardiovascular Education Group
Tony Das, MD
BTK Re-entry Technique
Tony Das MD FACCCardiovascular Education Group
5.9F profile device
6F sheath
.014” guidewire
120 cm length
22 gauge cannula
7mm long cannula
Tony Das MD FACCCardiovascular Education Group
Tony Das MD FACCCardiovascular Education Group
The role of CTO devices BTK
Tornus 2.1Fr
Tornus 2.6Fr
Tony Das MD FACCCardiovascular Education Group
Newer CTO devices
Clockwise: ReeKross, CiTop, Wildcat, CrossBoss, Stingray Others: ReVascualar RVT 0.016in drill, SI Therapies: Re-entry Balloon
Tornus 2.1Fr
Tornus 2.6Fr
Tony Das MD FACCCardiovascular Education Group
Summary
Previously unapproachable tibial CTO’s can be addressed novel wires, alternative access routes, newer true lumen crossing devices, and CTO re-entry devices
Acute procedural success includes PTA, cryoplasty, possibly atherectomy, and consideration for DEB and stents (DES)
Long-term results for PTA alone are dismal, but may lead to wound healing
Very few cases are truly “undoable”
Tony Das MD FACCCardiovascular Education Group