Case 1 Day 2
Q 4: What is your access approach strategy for this patient to facilitate successful CTO crossing
Q5: What is your guidewire escalation strategy and clarify the reasons for your choices ?
Q 6:The guidewire is unable to cross the lesion due to heavy calcification. Which type of guidewire should be selected next. Is there any other tools/approaches that can help crossing calcified CTOs?
Q 7: What is the most appropriate imaging modality for performing retrograde crural access?
Q 8:Following successful lesion crossing and balloon angioplasty, what closure device would be most suitable for your femoral and crural artery access?
A4 retrograde access through the crural arteries
a5- using commando wire or asahi
a6- using trailblazer or rubicon as support for crossing CTO
a7 angiography with using road map technique to obtain retrograde access
a8 pro glide or manual for femoral , endo vascular balloon angioplasty antegradely for crural or manual selective compression.
Q4:
good planing preintervention:
Q5:
use hydrophilic standard wire 0,035 to cross the contralateral side, better to replace it with drillin or CTO wire like ASAHI or command to avoid sub intimal approach
Q6:
use a stiff wire or drilling wire with supporting orCTO catheters to cross the lesion
Q7:
DuplexUS guided with fluoroscopic imaging guidance
Q8:
manual compression or by perclose ProGlide system
4-contralateral femoral or retrograde popliteal or tibial ot crural or brachial
5-cto wire as 0.14 or asahi wire
6- retrograde approach ( safari technique) , atherectomy device may be used
7- ultrasound guided insertion
8- proglide or manta for femoral , for crural manual compression
A1 ipsilateral femoral puncture U/S guided or contraletal femoral acsess
we may use retrograde approach
A2 1st soft tip standrad wire less traumatic
then stiff wire beteer pushability
we can use high tip load wire and CTO wires
A3 we can use support catheter for wire support
atherectomy devices
reentery devices
lithotrepsy devices for calcification removal
we can use retrograde approach
A4 U/S guided puncture
or angioprahic fluroscopic guided puncture
A5 for femoral
closure devices or manual compression
for crural artery manual compression
4- contralateral fem access with crossover sheath accounting good iliacs and distal aorta condition, retrograde access with micropuncture kit, a long sheath also is prepared for a lt brachial access taken into accoun, DUS machine
5- standard and stiff, 035 for crossover sheath placement, after initial angiogram ostial atheromatous cap morphology and geagraphy in ipsilat oblique view the main goal is to navigate through the plaque tracking microshannels and avoiding calcium depositions so start with low profile wire, 018 with tapered supporting cath is first option, if not possible a standard, 035 wire is used for subintimal plain creation taking into account reentry into true lumen
6-If Asahi wires are available especially wires with high tip load then retrograde access is done
7-duplex guided access facilitated by angiogram to select the best segment
8-manual compression if the access site is well supported by bone, vascular closure devices for cfa, ballon assissted closure for crural arteries and lastly open closure… It depends.
Q4:
>> US guided antegrade femoral access if more than proximal 1/3 of SFA is patent
if not feasible we may go for crossover technique through contralateral femoral puncture
or we may go for retrograde crural access.
Q5: Guidewire Escalation Strategy
> firstly standard soft tip hydrophilic guidewire as it is better in negotiating and less traumatic
> 2ndly we may go to a stiffer hydrophilic guidewire if the soft tip wire fails to penetrate as in moderate calcification is encountered.
> CTO wire if previous wires failed which is high tip load wires can help in lesion penetration
Q6
i will go with high tip load CTO wires may be with microcatheter or CTO crossing catheter for wire support and precise wire manipulation.
also we may use Reentry devices for subintimal reentry.
another option is Intravascular Lithotripsy (IVL), delivers shockwaves
Q7:
Ultrasound for access + Fluoroscopy for wire advancement ensures precision and avoiding complications.
Q8:
for the femoral access a closure device such as Perclose ProGlide or Angio-Seal.
for the Clcrural Access:
Manual Compression is ideal.
Q4: Contralateral retrograde femoral approach+/- retrograde ipsilateral pop or tibial vessel approach
Q5: Hydrophilic wires with it’s different profiles followed by cto wires
Q6: Using different approaches with hydrophilic wires like sub intimal approach and retrograde pop approach of failed cto wire should be considered
Q7:U/s guided access
Q8: Closure device for femoral access followed by manual compression
Retrograde access first trans luminal balloon inflation followed by manual compression
Q(4):
Contralateral CFA cross over with sheath using ultrasound guided punctureor Retrograde approach by epsilateral puncture of tibial vessels.
Q(5):
Hydrophilic guide wire then change to tapered end wire to cross the CTO lesion.
Q(6):
High tiped loaded wire to cross heavily calcified vessels with caution to prevent perforation and CTO support catheter.
Using atherectomy device to create a lumen or re-enetry device.
Q(7):
duplex U/S and fluroscopy
Q(8):
Manual compression is the best option or sutures if open wound.
4.Transfemoral antigrade Access , if its feasible.
Then trial of retrograde if needed.
5.stars with 0.018 nitinol coating wore to facilitat crossing the lesion , then change to 0.035 stainless steel core to support tools .
6.use a hydrophobic coating and higher tip load wire.
Use of Supporting catheter and guiding catheter may help crossing the lesion.
7.Duplex US guided Access.
8. Femoral access percutanous closure device and manual compression .
Access Approach Strategy for CTO Crossing
. Antegrade Femoral Access: +use Retrograde if needed vs hyprid approach under furoscopic and us. Guidance
Guidewire Escalation Strategy
According to availability first hydro philic wire first
Then wire for CTO crossings like asahi
Most Appropriate Imaging Modality for Retrograde Crural Access
Ultrasound-Guided Access:+Fluoroscopy
Closure Device for Femoral and
Crural Artery Access
According to availability manual compression is always available
Q4
-Ipsilateral CFA access if there is working distance
-Contralateral CFA if in flush occlusion present with normal iliac A
-Trans brachial if inflush occlusion whith contralateral iliac lesion
-Open using hyprid technique endarterectomy of CFA and access
Q5
A-,035 zip wire ( flexible tip with moderated loaded tip )
If failed
B-,.018 command wire ( flexible straight tip with strong shaft )
C-,035 stiff wire ( heavily loaded tip with strong shaft ,straight tsppered end )
D- CTO wire
Q6
,018 wire command with rubicon catheter
,035 stiff wire with trabilizer catheter
Q7
Us guided access with fluoroscopy
Q8
Manual compression
Closure kit
A4:
Access
Contralat femoral cross over sheath us guided hydrophilic 0.35 wire
Retrograde us guided or fleuro guided 0.18 wire sheathless and snaring the wire from the contra lat sheath to continue from above ante grade
Wire escalation
Hydrophilic 035 to cross over the sheath changed to hard loaded tip wire to cross the lesion asahi wire
If the wire couldn’t pass the lesion we can use support catheter, drilling technique or percutenous needle crushing technique retrograde access should be considered and proximal or distal dissection re entry with using of re entry devices with caution regarding the collaterals we also could use rendezvous technique
Closure devices
Contra lat fem with closure device or manual compression
Retrograde crural access closure manually
Q4: contralateral retrograde femoral access and cross over as there almost no room for the sheath in the ipsilateral femoral artery and may be after and another option is ipsilateral retrograde access through one of the patent tibial arteries
Q5 hydrophilic 0.018 guide wire to guide me to cross through the weakest point of the lesion
Q6: next wire may be the high loaded guide wire like ASAHI 12 g to break the calcified cap
i may add also supporting catheter to cross the cap or go for retrograde trial to cross the lesion
Q7: Ultrasound guide access is the best while fluoroscopic guided access is also feasible
Q8: Manual compression is all the time best modalities to secure my access
but if available i could use one of the percutaneous closure devices for the femoral access
Q4: Access Approach Strategy for CTO Crossing
. Antegrade Femoral Access: +use Retrograde if needed vs hyprid approach under furoscopic and us. Guidance
Q5: Guidewire Escalation Strategy
According to availability first hydro philic wire first
Then wire for CTO crossings like asahi
Q7: Most Appropriate Imaging Modality for Retrograde Crural Access
Ultrasound-Guided Access:+Fluoroscopy
Q8: Closure Device for Femoral and
Crural Artery Access
According to availability manual compression is always available
A4.. If the lesion is in the mid or distal SFA I will prefer CFA ipsilateral to give more support for the wire and if it in the mouth of SFA I will prefer contralateral CFA as an access site
A5 .. with that CTO I will use tapered ended wire which is more suitable for CTO. And tight stenosis due to excellent flexibility and trackability
A6.. I will use high tip loaded wire which has stiffer tip and better penetrability of CTO with caution to avoid vessel perforation . Other approaches include trial of lesion crossing from retrograde access also include subintemal crossing and reentery to the true lumen using reentery devices tools include atheretomy devices which drill through the lesion to creat a lumen for the vessel as
A7.. DUS is used for crural access also fluoroscopy could be used and using vessel calcification as a map
A8.. I will prefer manual compression for closure and if I will use closure device I will use suture based ones