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. 2024 Feb 27;4(5):359-372.
doi: 10.1016/j.jacasi.2023.11.017. eCollection 2024 May.

Tip Detection-Antegrade Dissection and Re-Entry With New Puncture Wire in CTO Intervention: Revolution Through 3D-Wiring

Kota Tanaka  1 , Atsunori Okamura  1 , Ryouhei Yoshikawa  2 , Etsuo Tsuchikane  3 , Masato Ishikawa  4 , Satoshi Suzuki  5 , Hiroyuki Nagai  5 , Akinori Sumiyoshi  1 , Masatsugu Kawahira  1 , Tomohiro Yamasaki  1 , Hiroaki Matsuda  6 , Mutsumi Iwamoto  1 , Satoshi Watanabe  1 , Keita Yamasaki  1 , Nobuaki Tanaka  1 , Yasushi Koyama  1 , Yoshitaka Iwanaga  1 , Heitaro Watanabe  1
Affiliations

Tip Detection-Antegrade Dissection and Re-Entry With New Puncture Wire in CTO Intervention: Revolution Through 3D-Wiring

Kota Tanaka et al. JACC Asia. .

Abstract

Background: The authors devised the tip detection (TD) method and developed AnteOwl WR intravascular ultrasound to standardize intravascular ultrasound-based 3-dimensional wiring for intraplaque tracking in chronic total occlusion (CTO)-percutaneous coronary intervention (PCI). The TD method also allowed antegrade dissection and re-entry (ADR). Combining TD-ADR with Conquest Pro 12 Sharpened Tip (CP12ST) wire, a new ADR wire with the strongest penetration force developed to date, enabled re-entry anywhere except calcification sites.

Objectives: This study investigated the efficacy and feasibility of TD-ADR by comparison of procedural outcomes with Stingray-ADR in CTO-PCI.

Methods: Twenty-seven consecutive CTO cases treated by TD-ADR with CP12ST wire between August 2021 and April 2023 and 27 consecutive CTO cases treated by Stingray-ADR with Conquest 8-20 (CP20) wire between March 2018 and July 2021 were retrospectively enrolled as the TD-ADR by CP12ST wire group and Stingray-ADR by CP20 wire group, respectively, from 4 facilities that could share technical information on these procedures.

Results: The success rate of the ADR procedure was significantly improved (27 of 27 cases [100%] vs 18 of 27 cases [67%], respectively; P = 0.002) and total procedural time was significantly reduced (median procedural time: 145.0 [Q1-Q3: 118.0-240.0] minutes vs 185.0 [Q1-Q3: 159.5-248.0] minutes, respectively; P = 0.028) in the TD-ADR by CP12ST wire group compared to the Stingray-ADR by CP20 wire group. There were few in-hospital major adverse cardiac and cerebrovascular events or no complications in either group.

Conclusions: TD-ADR by CP12ST wire can standardize highly accurate ADR in CTO-PCI.

Keywords: IVUS-based 3D wiring; antegrade dissection re-entry; chronic total occlusion; coronary intervention; tip detection method.

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Conflict of interest statement

Dr Okamura has received speaker fees from Terumo Corp. Dr Tsuchikane has received consulting fees from Asahi Intecc, Boston Scientific, and Kaneka. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Figures

None
Graphical abstract
Figure 1
Figure 1
Angiography- and IVUS-Based 3D Wiring (A) Angiography-based 3-dimensional (3D) wiring, (B) intravascular ultrasound (IVUS)-based 3D wiring using the tip detection (TD)–intraplaque tracking, and (C) IVUS-based 3D wiring using the TD-antegrade dissection re-entry (ADR). AO-IVUS = AnteOwl WR intravascular ultrasound; CTO = chronic total occlusion.
Central Illustration
Central Illustration
Differences Between Stingray-Based ADR and TD-ADR Illustrations of long-axis and short-axis procedures for (A) the current device-based antegrade dissection re-entry (ADR) including the Stingray-ADR and (B) AnteOwl WR intravascular ultrasound (AO-IVUS)–based ADR using the tip detection (TD) method (TD-ADR), respectively. The red words state the pros and cons of these procedures. CTO = chronic total occlusion.
Figure 2
Figure 2
Procedural Flow Up to IVUS-Guided Wiring (A to D) Procedural flow from antegrade guidewire escalation to the starting point of IVUS-guided wiring. Abbreviations as in Figure 1.
Figure 3
Figure 3
Transfer of Positional Information From IVUS Images to Fluoroscopic Images (A) Fluoroscopic and IVUS images of the second guidewire inside the CTO lesion 1 cm before the transitional site of the intimal and subintimal spaces. (B) Fluoroscopic images (a, b) and IVUS images (c) during the TD method, and (d) mentally created vascular image after the TD method. The numbers coincide with the numbered IVUS position images. Abbreviations as in Figure 1.
Figure 4
Figure 4
Creation of the Re-Entry Under IVUS Observation in TD-ADR (A to F) Illustrations of IVUS images during TD-ADR. CP12ST = Conquest Pro 12 Sharpened Tip; other abbreviations as in Figure 1.
Figure 5
Figure 5
Flow Diagram of Stingray-ADR by CP20 Wire and TD-ADR by CP12ST Wire Flow diagrams of the procedures (A) in the Stingray-ADR by Conquest 8-20 (CP20) wire group and (B) in the TD-ADR by CP12ST wire group. (A) Stingray-based ADR was performed in all the 27 cases just after 13 the primary antegrade wire escalation. Stingray-based ADR was successful in 18 cases; however, 9 cases required other methods, and only 1 case was unsuccessful. (B) TD-ADR was performed in 13 cases just after the primary antegrade wire escalation. However, TD-ADR was performed after TD–intraplaque tracking or the retrograde approach in 14 cases, and TD-ADR was successful in all cases. Abbreviations as in Figures 1 and 4.
Figure 6
Figure 6
Angiographic and IVUS Images During the Procedures Angiographic images (A) prior to the procedure and (B) during antegrade wire escalation, (C) angiographic and IVUS images and corresponding illustrations during TD-ADR, and (D) angiographic image after the procedure. Abbreviations as in Figures 1 and 4.
Figure 7
Figure 7
IVUS Images During TD-ADR and Corresponding Illustrations (A) The tip of the guidewire was vertically touching the wall of the true lumen. (B) One-half of the length of the tip enters the wall. (C) The tip and shaft entered the true lumen. (D) The microcatheter entered the distal lumen in the true lumen (Video 1). IVUS images during TD-ADR. Abbreviations as in Figure 1.
Figure 8
Figure 8
IVUS Images During TD-ADR for 4 Other Impressive Cases IVUS images from the start of vertical puncture (I) to successful re-entry puncture (II) during TD-ADR for (A) the case of the collapsed true lumen (Video 2), (B) the case of the flattened true lumen (Video 3), (C) the case of the true lumen with calcifications in the wall (Video 4), and (D) the previously reported case of the CTO body (Video 5). Abbreviations as in Figures 1 and 4.
See this image and copyright information in PMC

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