Received: 10 July 2018 Revised: 20 September 2018 Accepted: 29 October 2018

DOI: 10.1002/ccd.27987

CORE CURRICULUM

Algorithmic solutions to common problems encountered

during chronic total occlusion angioplasty: The algorithms
within the algorithm
Robert F. Riley MD, MS1 | Simon J. Walsh MD2 | Ajay J. Kirtane MD, SM3 |
R. Michael Wyman MD4 | William J. Nicholson MD5 | Lorenzo Azzalini MD, PhD, MS6 |
James C. Spratt MD7 | Sanjog Kalra MD, MS8 | Colm G. Hanratty MD9 |
Ashish Pershad MD10 | Tony DeMartini MD11 | Dimitri Karmpaliotis MD, PhD12 |
William L. Lombardi MD13 | J. Aaron Grantham MD14

1
Christ Hospital Heart and Vascular Center
and Lindner Center for Research and Abstract
Education, Cincinnati, Ohio Improved technical equipment, dissemination of best practices, and the importance of complete
2
Belfast Health and Social Care Trust, coronary revascularization have led to a renewed interest in coronary chronic total occlusion
Belfast, UK
(CTO) PCI. In particular, the hybrid algorithm has been associated with increasing procedural
3
Columbia University, New York, New York
success rates in the US. However, the hybrid algorithm only covers overarching strategies in the
4
Torrance Memorial Medical Center, Torrance,
overall approach to these lesions. Several technical challenges can occur during execution of
California
5
these approaches, each of which has several potential solutions. A systematic or algorithmic
WellSpan York Hospital, York, Pennsylvania
6
approach to dealing with these challenges could contribute to improved procedural efficiency
San Raffaele Scientific Institute, Milan, Italy
7
and higher procedural success. While there have been isolated attempts in the past to codify
St George's University Hospital NHS Trust,
London, UK approaches to each of these situations, there has not been a contemporary, comprehensive
8
Einstein Healthcare Network, Philadelphia, review of the potential solutions to these problems. We present 10 common problems encoun-
Pennsylvania tered during CTO PCI and a consensus hierarchical approach to them.
9
Belfast Health and Social Care Trust,
Belfast, UK KEYWORDS
10
Banner University Medical Center, Phoenix,
consensus, percutaneous coronary intervention, solutions
Arizona
11
Edward-Elmhurst Health, Naperville, Illinois
12
Columbia University, New York, New York
13
University of Washington, Seattle,
Washington
14
St. Luke's Mid America Heart Institute,
Kansas City, Missouri
Correspondence
Robert F. Riley, MD, MS, The Christ Hospital
Heart and Vascular Center, 2139 Auburn Ave,
Cincinnati, OH 45219.
Email: [email protected]

The hybrid algorithm for selecting crossing strategies for coronary catheter angiography: (1) anatomy of the lesion's proximal and distal
chronic total occlusions (CTOs) was initially reported in 2012 via con- caps, (2) anatomy of the vessel distal to the lesion's distal cap, (3) the
1
sensus of high volume CTO PCI operators (Figure 1) . In essence, the presence of useable collaterals, and (4) the length of the lesion occlu-
algorithm is predicated on four angiographic features seen on dual sion segment. The first three inform the operator whether to start

Catheter Cardiovasc Interv. 2018;1–12. wileyonlinelibrary.com/journal/ccd © 2018 Wiley Periodicals, Inc. 1

2 RILEY ET AL.

FIGURE 1 The hybrid algorithm

anterograde (well-defined proximal cap with a distal landing zone after continued education in CTO PCI. While the authors have striven to
the distal cap suitable for re-entry) or retrograde (ambiguity about the put these solutions in logical order to promote simpler, safer, and
location of the proximal cap, major side branches at the proximal or more cost-efficient maneuvers as initial steps, we recognize that this
distal cap and/or a poor distal landing zone, along with appropriate organization is based on limited retrospective data and encourage
collaterals). The length of the lesion then guides the operator as to clinical judgment in their implementation.
whether to attempt wire escalation or to move toward subintimal
reentry, although it has been recently proposed that subintimal strate-
gies should only follow failed wire escalation strategies 2. Since its
1 | W I R E I M P EN E T RA B L E C A P A L G O R I T H M
publication, use of the algorithm has been associated with increased
This problem often occurs while attempting to penetrate the proximal
CTO PCI adoption, procedural efficiency, and success rates 3–7.
cap, though it can occur with the distal cap as well, especially in post-
However, the hybrid algorithm only describes the overall
CABG patients. This section focuses on the strategy for approaching
approach to crossing these lesions (directionality and intimal versus
an impenetrable proximal cap (Table 2), though many of these
subintimal crossing). There are also several common technical
methods will work for an impenetrable distal cap as well, though some
challenges that can occur during implementation of these various
will be more difficult to implement from the retrograde approach.
approaches that have their own individual treatment algorithms.
This algorithm assumes that standard maneuvers have been
Table 1 is a list of 10 of the most common problems encountered dur-
implemented to maximize support and that the strongest, tapered-tip
ing CTO PCI. While there have been individual attempts to describe
penetration wires that are available have also failed to penetrate the
some of these challenges and their solutions in the past, these have
cap. Steps for maximal guide support include deeply intubating the
been limited to small case series or single technical reports. This
guide (“amplatzing” the guide) into the coronary, using a guide exten-
review describes a comprehensive, hierarchical review of contempo-
sion, and/or utilizing an anchor balloon either in a proximal side
rary solutions to these challenges in consensus recommended order
branch or a stented area in another vessel if possible (e.g., stented
based on accumulated experience to provide a framework for
proximal circumflex for a CTO lesion in a LAD or vice-versa), as shown
TABLE 1 Common problems encountered during chronic total in Figure 2.
occlusion percutaneous coronary intervention The first potential solution is BASE (“Balloon-Assisted Subintimal

Wire impenetrable cap Entry”) power knuckle. Note that this strategy depends on being able
Wire will cross cap/lesion but gear won't follow to complete either an anterograde dissection and re-entry (ADR) or
Cap ambiguity retrograde dissection and re-entry (RDR) procedure. If these options
Proximal cap ambiguity are not available to the operator, consider alternative options. This
Distal cap ambiguity maneuver consists of two parts. The first step is BASE, which gains
Difficult anterograde dissection re-entry entry into the subintimal space, followed by use of a power knuckle to
Wire across retrograde collateral but microcatheter will not follow get around the cap. First, leave the MC utilized during wire escalation
Septal collateral in-place. Then bring in 1:1 sized noncompliant (NC) balloon into the
Bypass graft collateral
Epicardial collateral TABLE 2 Wire impenetrable cap solution algorithm

Difficult retrograde dissection re-entry 1. Balloon-Assisted Subintimal Entry (BASE) power knuckle
Cannot externalize wire during retrograde dissection re-entry 2. Scratch-and-go
Wire/gear keeps going into a side branch around/within a lesion 3. Carlino
Difficult suture line to cross 4. Laser atherectomy
In-stent chronic total occlusions 5. Go retrograde
RILEY ET AL. 3

FIGURE 2 Ways to increase guide support. Panels A and B show before and after amplatzing a guide; panel C shows use of a guide extension
(arrow); panel D shows use of an anchor balloon in a proximal branch of an RCA (arrow)

vessel over a workhorse wire placed in the vessel proximal to the access to the subintimal space, which facilitates the gear traversing
impenetrable cap. Inflate the balloon proximal to the cap several times through the subintimal space and around the cap in the true lumen,
to a size 1:1 with the vessel, ideally at the site of plaque if possible; an similar to BASE. Step one is the scratch: a stiff tapered-tip penetration
NC balloon is utilized as it has a higher likelihood of creating a dis- wire is used to puncture into resistant tissue in the vessel wall archi-
section compared to a semi-compliant balloon. The goal here is to cre- tecture proximal to the cap. Confirmation of location of the wire tip
ate a dissection in the vessel architecture proximal to the cap in order within the vessel architecture (ensuring the wire tip is “dancing” with
to enter the subintimal space (“BASE”). After BASE, it is usually easiest the target vessel segment) should be done in multiple views and can
to facilitate wire passage into the sub-intimal space by “trapping” the be aided by the presence of calcium. After ensuring the wire tip and
MC parallel to the middle segment of the inflated balloon by inflating vessel architecture are moving in-phase in multiple views, advance the
the balloon. A polymer jacketed wire is then pushed into the subinti- MC tip just into the vessel wall architecture (no more than 1–2 mm).
mal space to form a knuckle proximal to the cap, subsequently bypass- The second step is “and-go”: once the tip of the MC is just into the
ing the impenetrable cap; it is termed a “power knuckle” due to the architecture of the vessel wall, switch out for a polymer jacketed wire
additional support afforded by the inflated balloon next to the MC and knuckle the wire in the subintimal space into the distal vessel
(Figure 3). If the wire makes satisfactory progress into the vessel architecture and set up for distal reentry distal to the distal cap in typ-
architecture, the balloon is deflated and the MC advanced as normal. ical fashion. Switching out for a knuckle as soon as possible will mini-
One caveat for using BASE in this scenario is that it relies on having a mize the risk of wire exit outside of the vessel architecture, while also
sufficient length of vessel proximal to the impenetrable cap to deploy confirming wire presence in the vessel architecture of the CTO body
a balloon. In very proximal or ostial lesions, this may not be feasible. prior to advancing secondary equipment. In contrast to BASE, where
A similar solution is termed a “scratch-and-go” (Figure 4). The idea dissection is blunt, the scratch-and-go method relies on forceful pene-
behind this maneuver is using a stiff wire to penetrate into the vessel tration with sharp wires. It is imperative that these stiff wires are not
architecture immediately proximal to the impenetrable cap to gain advanced over long distances to minimize the risk of wire perforation.
Most importantly, secondary equipment (e.g., MC, balloons) should
not be advanced until wire position is confirmed in the vessel
architecture.
A third solution is termed a “Carlino”, named for Dr. Mauro Car-
8
lino, who first reported the procedure . It involves a hydraulic

FIGURE 3 Example of Balloon-Assisted Subintimal Entry (“BASE”) FIGURE 4 Example of a scratch-and-go [Color figure can be viewed
Powerknuckle [Color figure can be viewed at wileyonlinelibrary.com] at wileyonlinelibrary.com]
4 RILEY ET AL.

microdissection of the cap by injection of a small volume of contrast TABLE 3 Wire across cap/lesion but gear will not follow solution
3
(<1 mL) through a MC using a high-pressure 2 cm luer-lock syringe algorithm
with the tip of the MC positioned on the proximal cap. The injection 1. Increase guide support
should be performed in a controlled manner and under fluoroscopic 2. Small balloon inflations
guidance to ensure that the injection does not extend to creating a 3. Balloon-Assisted Microdissection (BAM)
true perforation out of the adventitia of the vessel. After this maneu- 4. Switch to smaller profile microcatheter
ver, reintroduce a stiff wire and reattempt to puncture the proximal 5. Switch to stiffer microcatheter
cap using conventional wire escalation. It is useful to remember when- 6. Laser atherectomy
ever contrast is introduced in an MC, the wires can become sticky due 7. External cap crush
to the viscosity of the retained contrast; this can be overcome by 8. Carlino
flushing the MC with heparinized saline after the injection, prior to 9. Deliver a short roto wire and perform rotational atherectomy
reinserting a wire. 10. Go retrograde
A fourth solution is using a laser catheter to soften up the proxi- 11. See wire impenetrable cap algorithm
mal cap, much as the Carlino injection is intended to do. Start by bring
in a 0.9 mm laser catheter to the tip of the wire at the proximal cap to advance it through the lesion. If successful in advancing the balloon
and then perform laser atherectomy on the cap, typically from 30 sec though the lesion, switch out for the MC and proceed as normal. The
to several minutes. After laser atherectomy is complete, bring in a MC reason for using a 20 mm length balloon in this situation is that the
over the wire and attempt to puncture the cap again using conven- largest diameter of the profile for balloons <2 mm is the dot marking
tional wire escalation, similar to after the Carlino maneuver. the central portion of the balloon (as opposed to 2.0 mm and larger
A final solution for an impenetrable cap if the previous four solu- balloons that have markers on each end of the balloon). Therefore,
tions fail is to go retrograde. For cases in which the retrograde the longer length of the lower profile portion of these smaller balloons
approach is favorable, this step may occur sooner in the algorithm. prior to the central marker will allow them to be advanced further
Typically, the distal cap of the CTO is softer and easier to puncture than 2.0 mm and larger balloons. One caveat is that if this problem is
compared to the proximal cap, possibly due to chronic exposure to encountered while retrograde, balloons with longer shafts (e.g., Trek
collateral-supplied pressures versus the systemic pressures the proxi- [Abbott]) may be required in order to have the necessary length to
mal cap is exposed to. From a retrograde approach, it is often possible reach the occlusion.
to cross the proximal cap, either by retrograde wire escalation or sub- If these balloons will not advance, a next step could be BAM
intimally around the resistant segment. If a wire is able to traverse (Balloon-Assisted Microdissection aka “Grenadoplasty”). During this
past the resistant cap and lumen re-entry is not achieved from a retro- maneuver, the lower profile balloon that was initially used to try to
grade direction, it may also be possible to perform an “external” cap cross is now taken to the point it will no longer advance and then
crush by delivery of a balloon retrograde and inflating it at the site of inflated carefully until it deliberately ruptures in an attempt to create
the resistant cap, crushing the cap, and then re-attempt anterograde a microdissection of the resistant area of the lesion. This must be
strategies (see section 2). done in a careful manner under fluoroscopy, with quick deflation of
the balloon as soon as burst is noted by rapid loss of pressure in the
insufflator and/or noting burst under fluoroscopy via the flash of con-
2 | W I R E A C R O S S C A P / LE S I O N B U T GE A R
trast from the balloon rupture in order to reduce risk of vessel perfo-
W I L L N O T F O L L O W A L G O RI T H M
ration from the rupture of the balloon. This is also why this maneuver
should not be done with larger profile balloons. After the intentional
A second common problem encountered in CTO PCI is when the wire
balloon rupture, a second low profile balloon or MC can be brought in
crosses the proximal cap or other resistant area within the lesion but a
to reattempt lesion crossing.
MC will not follow. This is most commonly seen in a heavily calcified
After attempting BAM or if BAM does not work, switching out
and/or post-CABG lesion. The solutions to this problem are listed in
for a lower profile MC (Caravel [Asahi], Turnpike LP [Vascular Solu-
Table 3. These solutions can be grouped into those that involve work-
tions]) can be considered. If these will not cross, a stiffer MC can be
ing over the original wire that crossed the cap and those that involve
tried, such as a Tornus (Asahi) or Turnpike Gold (Vascular Solutions). If
sacrificing wire position.
this does not work, laser atherectomy of the cap/lesion with a 0.9 mm
laser catheter can be performed, as previously described.
3 | W O R K I N G OV E R T H E I N I T I A L WI R E Another method is to consider in this situation is an external cap
crush (Figure 5). The reason that a wire will cross a lesion and then
The simplest solution is increasing guide support, as previously men- the MC will not follow often occurs when the initial wire is in the true
tioned. If increasing guide support does not allow for advancement of lumen with too much resistance from the plaque in the lumen, limiting
the MC through the cap/lesion, a next step would be to switch the the ability for the MC to cross. In order to overcome this, a second
MC out for a 1.0, 1.2/1.25, or a 1.5 mm × 20 mm semicompliant bal- wire/MC system can be taken into the subintimal space, “external” to
loon. This balloon is advanced as distally as possible. Serial high- the lesion in the true lumen, and used to modify (“crush”) the resistant
pressure inflations are then performed with this balloon in an attempt area. There are three steps to this procedure. First, with the initial
RILEY ET AL. 5

FIGURE 5 External cap crush [Color figure can be viewed at wileyonlinelibrary.com]

wire left in-place, perform a scratch-and-go or BASE with a second only 9. This technique has been used safely in the intimal and subinti-
wire/MC system proximal to the cap, then switch out for a low gram mal space . If these techniques fails, revert to the “Wire Impenetra-
10

force polymer jacketed wire and knuckle this wire around the resistant ble Cap” algorithm or switch to a retrograde approach.
cap/lesion in the subintimal space. Then, switch out the MC on the
knuckled wire for a 1:1 sized NC balloon and take the balloon in the
subintimal space to the site of the resistant cap/lesion in the true
5 | C T O CA P A M B I G U I T Y A L G O R I T H M S
lumen, then inflate it to match the size of the vessel, thereby “crush-
ing” the cap/lesion and modifying it from the subintimal space. Then, 5.1 | Proximal cap ambiguity
remove the NC balloon out of the subintimal space and attempt to At times, there will be ambiguity regarding the anatomic site of one of
move an MC over the original wire past the previously resistant site. the caps of a CTO lesion. This can be due to branches around the cap,
bypass grafts at the cap site, poor visualization from angiography, etc.
The algorithm for solving proximal cap ambiguity can be seen in
4 | SOLUTIONS THAT REQUIRE
Table 4. An initial solution to solving proximal ambiguity is to bring in
S A C R I F I C I N G TH E I N I T I A L WI R E P O S I TI O N
a wire and MC retrograde to define and mark the vessel course with
either a wire or knuckle that is brought close to or past the proximal
These steps should only be performed if the above steps, which allow
cap to serve as a marker for the vessel course and to direct the anter-
retention of wire position are not successful. The first of these steps
ograde wiring attempt.
is performing a Carlino maneuver at the resistant site to try and alter
If unable to go retrograde, a second solution involves utilizing
the plaque in the resistant segment. If unsuccessful, the final antero-
IVUS to resolve the ambiguity of the cap location if a side branch is
grade step involves rotational atherectomy over a knuckled or
present that is close enough to the cap and large enough to pass an
shortened Rota-Floppy wire (Boston Scientific). This is achieved by
IVUS catheter into. The side branch is wired and an IVUS catheter
advancing an MC (preferably low-profile) as far as possible over the
advanced into the branch. A pullback will often illustrate the site of
index wire. The original wire is removed from the distal vessel. The
the cap (Figure 6). If an adequate diameter guide catheter is in place,
Rota-Floppy wire is then advanced as far as possible into the CTO
the IVUS can be left in situ and a MC and wire can then be brought
segment beyond the MC, ideally, on a distal knuckle to move the
into the vessel in parallel to attempt to puncture the cap under direct
radio-opaque segment well beyond the area where plaque modifica-
IVUS visualization.
tion is planned. If this is not feasible, the wire can be modified by cut-
Another method of using the side branch to resolve vessel ambi-
ting the majority of the radio-opaque segment off (although still
guity is Side-Balloon-Assisted Subintimal Entry (“S-BASE”, Figure 7).
retaining enough for the tip to be visible on fluoroscopy), thereby
This maneuver involves taking a semicompliant balloon (sized 1:1 with
allowing the 0.01400 radio-opaque segment to move sufficiently far
the side branch) over a wire in the side branch and inflating it to
beyond the area planned for atherectomy. Very focused rotational
extend from the side branch into the proximal vessel. With the balloon
atherectomy is then performed and limited to the resistant segment inflated, a looped polymer jacketed wire is pushed through a MC in
the main vessel proximal to the bifurcation. The inflated balloon will
TABLE 4 Proximal cap ambiguity solution algorithm
deflect this knuckled wire away from the side branch and into the
1. Go retrograde
main vessel. This maneuver has the benefit of preserving the side
2. IVUS-guided puncture of cap if side branch is available
branch and resolving vessel ambiguity 11.
3. Side Balloon-Assisted Subintimal Entry (S-BASE)
If a retrograde approach is not feasible and no major side branch
4. Balloon-Assisted Subintimal Entry (BASE) power knuckle
is present in the vicinity of the cap, proximal cap ambiguity can also
5. Scratch-and-go
be solved with either a BASE power knuckle or scratch and go in order
6. Coronary computed tomographic angiography
to get into the subintimal space at an unambiguous site in the vessel
6 RILEY ET AL.

FIGURE 6 Example of IVUS-guided resolution of LAD CTO proximal cap ambiguity by performing IVUS over a wire in a diagonal branch and
identifying the proximal cap at the bifurcation of the LAD and diagonal branch (arrows)

architecture proximal to the cap, allowing subintimal knuckling within

the vessel architecture around the ambiguous cap site. If all of these
methods fail or the ambiguity is anticipated preprocedurally, coronary
computed tomography angiography (CCTA) may be useful in order to
lay out the trajectory of the vessel and direct the initial or subsequent
attempt.

5.2 | Distal cap ambiguity

The algorithm for solving distal cap ambiguity can be seen in Table 5.
This scenario is common in post-CABG patients where the distal cap
is close to or lies on a graft suture line and the wire/equipment con-
tinues to migrate into the graft instead of the native epicardial vessel.
An initial way to solve this problem is with a distal MC tip injection
using contrast and a 2 cm3 luer-lock high-pressure syringe. As contrast
is injected, withdrawal of the MC will often illustrate the distal cap
and graft anastomosis if present. This can then direct the next attempt
to puncture the distal cap. It may also result in staining of the subinti-
mal space (essentially a retrograde Carlino maneuver), which can pro-
vide the operator with a map of the vessel to track. If this does not
work, an anterograde knuckle can be advanced into the distal vessel
architecture to the ambiguous segment. This can be used as a marker
for retrograde wire advancement, solving the anatomic ambiguity of
the distal cap, similar to the method used to solve proximal cap ambi-
guity described above.
Another solution is to perform BASE over the retrograde wire,
creating a dissection distal to the cap, and then switching out for a
polymer jacketed wire to knuckle retrograde within the subintimal
space to solve the ambiguity. It is always safer to solve anatomic
ambiguity with knuckles versus directional wiring given that the

TABLE 5 Distal cap ambiguity solution algorithm

1. Retrograde microcatheter distal tip injection

2. Mark distal vessel course with anterograde knuckle and then use stiff,
tapered wire retrograde to puncture into vessel architecture
3. Retrograde Balloon-Assisted Subintimal Entry (BASE), then switch
out for knuckle
4. Leave retrograde balloon in-place for controlled anterograde and
retrograde tracking and dissection (CART) or facilitated anterograde
dissection reentry (ADR)
FIGURE 7 Illustration of side-BASE (S-BASE) [Color figure can be
5. Coronary computed tomography angiography
viewed at wileyonlinelibrary.com]
RILEY ET AL. 7

knuckles will track the vessel architecture while wiring alone is more Stingray catheter prior to performing the stick-and-drive or stick-and-
prone to perforate the vessel. During any of these maneuvers, there is swap. This can be left attached for several minutes for blood to be
always the option of leaving the retrograde wire in-place and bringing withdrawn from the space around the reentry site. STRAW can also
in a retrograde balloon into the distal vessel and performing controlled be performed by introducing a parallel OTW balloon into the vessel
anterograde and retrograde tracking and dissection (CART) or facili- over a second wire system; this balloon should be sized 1:1 with the
tated ADR, as previously described 12,13. Finally, if these methods fail, vessel. The balloon is taken into a vessel segment just proximal to the
CCTA can be performed to lay out the trajectory of the vessels to proximal cap of the CTO, inflated, and then after wire removal, a
inform the initial or subsequent attempt. syringe is attached to the proximal port for continuous suction of
blood from the subintimal space. This method blocks the inflow and
reduces hematoma, facilitating re-entry 14.
6 | DIFFICULT ANTEROGRADE DISSECTION The next solution to this problem could be to wire redirect into a
R E E N T R Y A L G O RI T H M different subintimal plane (ideally closer to the true lumen) and then
re-set up ADR. If this fails, leave the anterograde wire and MC in-
ADR is unsuccessful in ~30% of cases 1. Given this, we have devel- place and switch to a retrograde strategy to set up for RDR.
oped an algorithm to address this common problem, as seen in If these methods fail, LAST (Limited Anterograde Subintimal
Table 6. If the initial Stingray MC (Boston Scientific) has been cor- Tracking) can also be attempted at this point, where the subintimal
rectly deployed at the target landing zone but wire puncture into the space is fenestrated into the true lumen with a stiff wire several times,
true lumen fails, then “bob-sledding” can be attempted. This involves followed by wiring the true lumen with a medium weight polymer
deflating the Stingray catheter and moving it over a stiff wire reintro- jacketed wire. This is very similar to the approach utilized with the
duced through the distal lumen of the catheter and into a more favor- Stingray catheter, though this method is less successful than ADR
able location within the vessel architecture (less calcium, closer to the using a Stingray catheter 15. IVUS can also be helpful in guiding LAST.
true lumen, less tortuous, less hematoma), either proximal or distal to To perform this, an IVUS catheter is advanced over the subintimal
the previously attempted site, and then reattempting ADR at this wire and used to determine the location of the true lumen. A second
location. wire/MC system is then taken into the subintimal space next to the
Failure to puncture with a Stingray wire may also be overcome by first system and a stiff wire is used to puncture into the true lumen
the use of an appropriately shaped specialist CTO penetration wire under IVUS guidance - this is similar to IVUS-guided parallel wiring 2.
(e.g., Confianza Pro12 [Asahi], Hornet 14 [Boston Scientific], Astato Finally, if the procedure has failed both anterograde and retro-
20 or 40 [Asahi]) in order to fenestrate into the distal lumen. The con- grade approaches (or retrograde is not a possibility), then a Subintimal
16
cept here is that stiffer wires with different tip bends can puncture Tracking And Reentry (STAR) procedure can be performed . The
into the true lumen when the pre-bent Stingray wire (Boston Scien- goal here is to advance a deliberately knuckled wire anterograde and
tific) fails to do so. This step can be performed as a “stick-and-drive” let it re-enter the true lumen distally, usually at a bifurcation; this will
using the specialist CTO penetration wire or by “stick-and-swap” be noted by a quick shrinkage of the knuckle as it moves from the
where the vessel is punctured by the specialist CTO penetration wire subintimal to luminal space (be sure to store the fluoroscopy images

and then switched out for a polymer-jacketed medium gram force noting this reentry location). The knuckle is then followed by the MC

wire, which is used to enter the distal true lumen through the punc- to dotter the entry into the true lumen, followed by predilating the

ture made by the specialist CTO penetration wire. lesion and subintimal space past the reentry site of the knuckle into

A common reason ADR fails is due to hematoma formation in the the true lumen to ensure outflow. Studies have shown that perform-

subintimal space, which compressed the true lumen, and makes re- ing a STAR with adequate outflow (≥2 branches distal to the reentry
zone), leaving the vessel to heal for several weeks, and then bringing
entry into this space more difficult. A solution to this problem is Sub-
the patient back for repeat PCI attempt will result in recruitment of
intimal TRAnscatheter Withdrawal (STRAW) of the subintimal space.
more distal branches and in shorter segments that require stenting
This is achieved by a number of potential steps. The simplest is placing
compared to stenting during the initial STAR procedure 16,17. Alterna-
a syringe with negative pressure on the over-the-wire port of the
tively, if the distal knuckle fails to re-enter the true lumen distally, sub-
TABLE 6 Difficult anterograde dissection re-entry (ADR) solution intimal plaque modification can also be performed, as previously
algorithm described, which has been shown to be independently associated with

1. Bob-sled better patient-reported health status at 30 days 18.

2. Using a stiffer, tapered wire for stick-and-go or stick-and swap

3. Subintimal transcatheter withdrawal (STRAW) via stingray or a OTW
balloon 7 | WIRE ACROSS RETROGRADE
4. Wire re-direct into a different subintimal plane closer to the true C O L L A T E R A L BU T M I C RO C A T HE T ER WI L L
lumen and attempt ADR at this new location NOT FOLLOW ALGORITHMS
5. Go retrograde to set up for retrograde dissection re-entry
6. Limited Anterograde Subintimal Tracking (LAST) Performing a retrograde CTO procedure requires both successful wir-
7. Subintimal tracking and re-entry (STAR) or subintimal plaque ing and MC passage through the retrograde channel, whether septal,
modification
epicardial or bypass graft. If the wire is able to negotiate the channel
8 RILEY ET AL.

but the MC is unable to follow, there are several solutions, depending TABLE 8 Wire across bypass graft collateral but microcatheter will
on the channel used. not follow
1. Increase guide support

7.1 | Septal algorithm 2. Wire escalation

3. Lower profile microcatheter
The solutions for septal microcatheter issues can be seen in Table 7.
4. Blocking balloon in distal grafted vessel
Resistance occurs most frequently at the inferior portion of the sep-
5. Trap retrograde wire with anterograde balloon
tum or when a very proximal first septal connects circuitously (and
sometimes epicardially) into the posterolateral branch. Assuming a
same segment and a balloon inflated to trap the retrograde wire and
meticulous MC spin technique is being utilized, the initial solution is
provide a better rail for delivery of the retrograde MC, as noted
to increase guide support, as previously described in the “Wire Impen-
above.
etrable Cap” algorithm. The next approach is to inflate a 1.0, 1.2/1.25
or 1.5 × 20 mm balloon at low pressures at the resistant spot in the
septum, then re-attempt crossing with the MC. If unsuccessful,
7.3 | Epicardial algorithm
exchange for a lower profile MC. If these will not pass, dottering the The solutions for having a wire across an epicardial collateral but the
retrograde channel with a 135 cm MC may provide more torsion to MC will not follow can be seen in Table 9. There are fewer options for
dilate the channel, with subsequent exchange back for the 150 cm solving this issue due to the more fragile nature of epicardial collat-
device. Alternatively, if the retrograde wire has progressed sufficiently erals and higher risks from a perforation compared to septal or bypass
into the lesion, anterograde equipment can be brought to the same graft collaterals—this is why balloon dilation of the epicardial vessel is
segment and a balloon inflated to trap the retrograde wire and provide more dangerous than for septals and should be avoided. The solutions
a better rail for delivery of the retrograde MC. Finally, if a softer wire involve increasing guide support, followed by using a lower profile
(e.g., Sion or Suoh03 [Asahi]) has been used to cross the channel, MC. If these two solutions do not work, the final strategy is trying
attempting to rewire with a wire with a stiffer body (e.g., Fielder FC another collateral or switching back to an anterograde strategy, leav-

[Asahi]) may provide a stiffer rail to take the MC across. If none of ing the retrograde wire as a marker in the distal vessel.

these solutions are successful, switching to another collateral or to an

anterograde strategy may be necessary, leaving the retrograde wire as
8 | D I F F I CU L T R E T R O G R A D E D I S S E C T I O N
a marker for the distal vessel to facilitate anterograde approaches
R E E N T R Y (R - C A RT ) A L G O R I T H M
or CART.

A common issue that arises during R-CART involves the inability to

7.2 | Bypass graft algorithm make the connection between the retrograde and anterograde equip-
ment. The solutions to this scenario can be seen in Table 10. The most
MC challenges in bypass grafts often occur at the retroflexed turn of
frequent reason the connection cannot be made is under-sizing the
the distal anastomosis. Solutions to this scenario can be seen in
balloon used to make the connection. This can be solved by bringing
Table 8. Guide support assumes an even greater role when a graft is
in an IVUS catheter on the anterograde wire to visualize the size of
used as the retrograde channel. Preloading the guide catheter with a
the vessel and subsequently appropriately size the balloon (1:1 sized
guide extension prior to wire and MC crossing is recommended. If the
with vessel size) used to facilitate making the connection. IVUS can
MC is not making the turn, using a stiffer wire and/or a lower profile
also be used here to see if the anterograde and retrograde equipment
MC should be attempted. If unsuccessful, a second wire can be
are in the same space (true lumen versus subintimal) or differing
advanced down the graft into the distal limb of the grafted vessel, and
spaces, which can also change the method of making the connection
a 1:1 sized semi-compliant “blocking” balloon can be inflated just distal
(differing spaces often requires a stiffer wire to puncture the subinti-
to the anastomosis to help support the retrograde MC as it is making
mal tissue plane that separates the two systems). If IVUS is not an
the turn. Alternatively, if the retrograde wire has progressed suffi-
option, the balloon can be serially upsized given the high likelihood
ciently into the lesion, anterograde equipment can be brought to the
that the original balloon was undersized.
The next solution is to use a higher penetration wire with a longer
TABLE 7 Wire across retrograde septal collateral but MC will not
follow bend to penetrate the tissues plane that may be between the two sets
of equipment. The safety of this step can be enhanced by placing a
1. Increase guide support with guideliner, amplatz guide, anchor balloon
guide extension over the anterograde equipment in order to leave as
2. Balloon septal with 1.0, 1.2/1.25 mm (or 1.5) × 20 mm balloon
short a distance as possible for the stiff wire to traverse. A third
3. Dotter channel with 135 cm MC, then switch back to 150 cm MC
4. Use lower profile MC TABLE 9 Wire across retrograde epicardial collateral but
5. Switch out for stiffer wire microcatheter will not follow
6. Try another collateral
1. Increase guide support
7. Go anterograde, leaving retrograde gear for controlled anterograde
2. Use lower profile microcatheter
and retrograde tracking and dissection (CART) or facilitated
anterograde dissection reentry (ADR) 3. Try a new collateral or go anterograde
RILEY ET AL. 9

TABLE 10 Difficult retrograde dissection reentry (R-CART) sized for the guide/guide extension), pinning the retrograde wire. This
1. IVUS-guided sizing of balloon used to make connection and identify enables tension to be put on the retrograde wire to rail the retrograde
locations of anterograde and retrograde gear MC into the anterograde guide. This is obviously not possible when a
2. Use higher penetration wire with longer bend single guide and an ipsilateral collateral channel has been crossed.
3. Use of anterograde guide extension Inserting a second guide and wiring it will allow this balloon anchoring
4. Move re-entry point proximally or distally technique to be performed in the case of an ipsilateral retrograde
5. Switch to controlled anterograde and retrograde tracking and approach. This is often referred to as using “ping pong” guides 19.
re-entry (CART) or facilitated anterograde dissection re-entry (ADR)
If the MC cannot cross despite these techniques, it is possible
that the MC may have been damaged or “fatigued” in the process of
solution is to move the point where the connection is being made
getting retrograde access and through the distal cap. Significant vessel
either more proximally or distally depending on where the two sys-
tortuosity and/or excessive manipulation of the MC can lead to kink-
tems appear to be closest together along the length of the vessel.
ing of the MC, especially if it is a coiled MC (Corsair [Asahi], Turnpike
If these methods fail, the retrograde MC can be exchanged for a
[Teleflex]). The tip of the MC can also become blunted or damaged
balloon and left in the distal vessel as a marker for CART. Another
passing through the distal cap and through the CTO segment. Switch-
solution that utilizes a balloon on the retrograde wire in the distal ves-
ing to a fresh MC in this situation should be considered early. One
sel is “facilitated ADR”, where the retrograde balloon is used as a
way that MCs can be classified is as braided (Finecross [Terumo], Car-
marker for the true lumen to guide reentry during ADR 13.
avel [Asahi]) which have lower crossing profile but are nontorquable
versus coiled (Corsair, Turnpike), which have a larger crossing profile
but are torquable and more robust. Switching from a braided to a
9 | INABILITY TO EXTERNALIZE WIRE
coiled MC may allow additional push through the CTO (assuming the
D U R I N G R - C A RT A L G O R I T H M S
crossing profile allows delivery). However, sometimes switching from
a coiled to a braided MC may remove enough friction from the system
9.1 | Retrograde wire is in anterograde guide but the to allow the MC to track more freely.
MC will not follow If a new MC still will not pass, consider a retrograde balloon infla-
This section will cover the scenario when the retrograde equipment tion at the site where the MC is getting stuck to disrupt the CTO seg-
(wire or wire plus MC) is in the anterograde guide/guide extension ment. Balloons with long shafts (140–150 cm), such as a Trek (Abbott)
during R-CART but there are difficulties externalizing the wire through are preferable for this maneuver. After dilation, switch back to the
the anterograde guide. It is not uncommon to manipulate the retro- MC. If the MC is close to the anterograde catheter and a good con-
grade wire into the anterograde guide then discover that the MC will nection has been made, then re-wiring with a long (>300 cm) wire
not follow easily. This can be due to a combination of factors including may facilitate externalization. Often the MC fails to advance in this
plaque burden within the CTO or MC fatigue and/or damage due to situation due to the degree of plaque burden especially if it is calcified.
the friction within the system. Bringing in an anterograde balloon (even in the subintimal space) can
Solutions to this problem are listed in Table 11. An initial solution modify the plaque/vessel at the site where the MC is failing to cross
is to inflate a trapping balloon in the anterograde guide (appropriately and may allow the MC to advance.
If these methods fail, wiring an anterograde MC with the retro-
TABLE 11 Inability to externalize wire during reverse controlled grade wire (“tipping-in”) can be performed (Figure 8). This is best
anterograde and retrograde tracking and re-entry (R-CART) achieved on the outer curvature of the anterograde guide, though this
Retrograde wire is in anterograde guide but microcatheter will not follow can also successfully be performed in the coronary as well. The anter-
1. Inflate a trapping balloon in anterograde guide fixing the retrograde ograde MC is then advanced over the retrograde wire as the retro-
wire grade MC is withdrawn. If these methods fail, a retrograde balloon
2. Switch out for fresh or new type (coiled versus braided) of can be brought in for CART or facilitated ADR.
microcatheter
3. Modify resistant segment with anterograde balloon inflation
4. Balloon dilate the collateral channel and CTO segment with 9.2 | When the retrograde MC has reached the
retrograde balloon anterograde guide, but the externalization wire will
5. Rewire with a 300 cm wire for externalization
not progress
6. Tip-in
7. Controlled anterograde and retrograde tracking and re-entry (CART) Once the MC is in the anterograde guide or guide extension, an exter-
or facilitated anterograde dissection re-entry (ADR) nalization wire is typically inserted to complete the case. The common
Retrograde MC in anterograde system but unable to externalize externalization wires used are the R350 (0.01300 , 350 cm wire, Vascu-
1. Switch type of externalization wire between R350 to RG3 lar Solutions), which has a stiffer, nitinol body and the steel-bodied
2. Roto glide in microcatheter for lubrication RG3 wire (0.01000 , 330 cm, Asahi). However, sometimes it is not possi-
3. Tip-in in aortic arch with a fielder XT3 ble to externalize the wire due to friction within the system. Switching
4. Balloon retrograde channel between externalization wires is an option to overcome this problem.
5. Controlled anterograde and retrograde tracking and re-entry (CART) The R350 is more pushable and less prone to kinking but is thicker,
or facilitated anterograde dissection re-entry
whereas the RG3 has a lower profile and creates less friction but can
10 RILEY ET AL.

TABLE 12 Wire/gear track into a side branch at a cap or within a

lesion algorithm
1. Wire-redirect with a longer bend on a penetration wire to direct
away from the side branch and into the main vessel
2. Dual lumen catheter over wire in side branch
3. IVUS into side branch to define location of CTO in main epicardial
4. Side Balloon-Assisted Subintimal Entry (S-BASE)
5. Knuckle with pilot 200 to bypass branch
6. Balloon-Assisted Subintimal Entry (BASE) power knuckle proximal to
bifurcation
7. Scratch-and-go
8. Carlino to define where you are and to cause dissection into main
epicardial
9. Retrograde access with retrograde equipment acting as marker for
anterograde puncture

FIGURE 8 Example of tip-in in the aortic arch. The two white arrows An initial solution to this problem is putting a longer bend on the
indicate a microcatheter being advanced anterograde while the black wires being used for cap penetration in order to direct away from the
arrow represents a wire being advanced retrograde though the same side branch and into the lesion. A dual lumen MC can also be used in
guide. The most likely place they will meet in the guide is in the aortic this situation to significantly aid in redirection and augment penetra-
arch, where they will both hug the outer curvature of the guide. Once
tion force. To utilize a dual lumen MC in this situation, a workhorse
they meet, the microcatheter can be slid over the wire and into the
vessel until the wire comes out of the distal end of the microcatheter wire is placed in the side branch and the dual lumen MC advanced so
that the OTW port aligns with the CTO cap. Wire escalation can then
be less pushable and may be more prone to kink. Another solution is be performed through the OTW port to puncture the cap. IVUS can
to inject a lubricant such as RotoGlide (Boston Scientific) through the be helpful in this scenario as well to both define the location of the
retrograde MC and attempt to externalize again. main vessel and to direct the wire penetration under live visualization.
If these maneuvers are still unsuccessful, tip-in can be performed Another method of using the side branch to bypass the CTO cap and
as described previously. Alternatively, an anterograde trapping balloon resolve vessel ambiguity is S-BASE, as previously described in the
can also be used in this situation to trap a short wire or long wire that proximal cap ambiguity section above.
is not fully externalized from the retrograde MC within the antero- Other solutions exist that can put the side branch in jeopardy.

grade guide. This will allow removal of the retrograde MC, followed The simplest is knuckling a Pilot 200 wire (Abbott) proximal to the side

by subsequent balloon dilation of the retrograde channel to reduce branch and using the larger size of the Pilot 200 knuckle to direct
away from the smaller lumen of the side branch and toward the large
the friction points. A further switch out for a new retrograde MC may
lumen of the main epicardial vessel. An alternative is to perform a
allow for externalization. Finally, the retrograde MC position can be
BASE power knuckle or scratch-and-go proximal to the bifurcation in
sacrificed, and the device withdrawn. The MC can be swapped for a
order to enter the subintimal space prior to the bifurcation and there-
retrograde balloon to facilitate CART or facilitated ADR.
fore stay out of the side branch. A Carlino injection can also be
performed to define where the bifurcation is and create a dis-
section into the main vessel in order to better inform a reattempt at a
1 0 | W I R E / G E A R TR A C K I N T O A S I D E
wire redirect with a longer tip bend. If all of these steps fail, the anter-
B R A N C H A T A CA P O R W I T H I N A LE S I O N
ograde gear can be left as a marker in the proximal vessel and retro-
ALGORITHM
grade gear brought past the side branch takeoff, then using the

A side branch is a common finding in mature occlusions, either at the retrograde gear as a marker for anterograde puncture with a stiffer
20 penetrating wire.
site of the proximal cap or within the lesion . It can create technical
problems for recanalization by masking the main epicardial vessel
course (ambiguity) and/or reducing the penetration force of the wire
1 1 | D I F F I C U L T Y CR O S S I N G D U E T O G R A F T
into the main vessel (the side branch creates a side load on the wire,
INSERTION (SUTURE LINE) ALGORITHM
thereby reducing the force of penetration into the CTO body). While
the hybrid algorithm suggests a retrograde approach for CTO lesions In post-CABG patients, crossing graft insertions can be difficult due to
where the proximal cap is either ambiguous (often due to a side the fibrotic nature of suture lines. The strategy for crossing the
branch) or when a major side branch exists at the cap, there will be sit- sutures shown in Table 13 starts with wire escalation, followed by
uations where either the retrograde approach is not an option or has wire escalation from the opposite direction (try retrograde puncture if
been failed and an anterograde approach that involves a side branch started anterograde or vice-versa) as these suture lines may not have
is required. The various solutions to this problem can be seen in homogenous fibrosis. If resistant to wire escalation from both direc-
Table 12. tions, a Carlino injection from one or both directions can also be used
RILEY ET AL. 11

TABLE 13 Difficulty crossing due to graft insertion (suture line) orthogonal X-ray views are taken as the wire progresses in order
solution algorithm to ensure that progress remains within the stent architecture and
1. Switch to retrograde approach if failing anterograde or anterograde if does not weave in and out of stent struts. If the MC progresses,
failing retrograde
then pursuing further wire-based crossing is reasonable, though the
2. Bilateral Carlino to define anatomy and try to dissect suture line
CrossBoss can be reintroduced to complete the lesion crossing here
3. Laser atherectomy of the suture line
as well.
4. Balloon-Assisted Subintimal Entry (BASE) from either direction
For lesions with the proximal cap in-stent and the distal cap
5. Knuckle a Confianza Pro12/hornet 14 if can't wire escalate across
from either direction beyond the distal stent edge, the approach depends on whether the
distal cap is at a bifurcation. If not, starting with a CrossBoss is reason-
able. The CrossBoss should be advanced beyond the distal cap, with
to cause micro-dissections in the suture lines and soften them up for luminal position checked via gentle advancement of a workhorse wire.
subsequent wire escalation. Laser atherectomy at the suture line can If the device has passed to the sub-intimal space, Stingray-based ADR
also be performed here as the laser can often soften the suture line can be performed. However, if the distal cap is at a bifurcation, a ret-
up for subsequent wire escalation, similar to the procedure described rograde approach is typically preferred in an attempt to preserve the
in the wire impenetrable cap algorithm above. Another option is to try bifurcation, as directed by the hybrid algorithm. Retrograde wire esca-
BASE power knuckle proximal to the suture line to try and go around lation can then be attempted if the distance of the segment from the
the suture line. If these methods fail, a stiff, tapered wire can be stent edge to the distal cap bifurcation is short. Alternatively, for lon-
knuckled past the suture line, followed by immediate deescalation to a
ger lesions (>20 mm), R-CART can be completed in the segment distal
jacketed, tapered wire to ensure you are still within the vessel archi-
to or within the stent, after crossing the proximal cap within the stent
tecture and without vessel perforation.
architecture.
If the proximal cap of the CTO is proximal to the proximal stent
edge with the distal cap in-stent, wire escalation or knuckling to the
12 | IN-STENT CTO ALGORITHM
proximal stent edge can be performed, using the stent as a marker to

CTOs that include in-stent restenosis can provide specific challenges. puncture into the stent with a stiff wire. Once position is confirmed

The various solutions for CTOs involving stents are shown in Figure 9. within the stent, the MC cab be exchanged for a CrossBoss, which is
The solution depends on whether the caps are within, proximal, or advanced past the distal cap, finishing by confirming position in the
distal to the stent, as shown. For lesions with both caps contained in true lumen of the distal stent with a workhorse wire. Alternatively, R-
the stent, a CrossBoss (Boston Scientific) is an excellent initial strat- CART could be performed proximal to or in-stent.
egy as it will likely cross the distal cap in-stent 21
. If the CrossBoss Finally, if both the proximal and distal caps extend beyond the
will not advance through the stented segment (often due to a stent stent, it is recommended to attempt to wire into the stent from which-
strut or edge), it can be wire-redirected into the CTO body. If the ever direction is most feasible. Wire escalation or dissection re-entry
CrossBoss does not penetrate the proximal cap, or stalls within the can be completed subsequently. However, if unable to stay within the
CTO body (often occurs in marked tortuosity) then it is usually neces- stent architecture (often due to mechanical issues within the stent
sary to switch out for a MC and wire. On occasion, medium polymer such as underexpansion, fracture, etc.), a final strategy is to wire or
weight jacketed wires will progress in the lesion, although high pene- knuckle around the old stent and crush it out of the way, usually by
tration force tapered wires are often needed. It is important that R-CART, completing the case by stenting alongside the old stent 22.

FIGURE 9 Solutions for CTOs involving in-stent restenosis [Color figure can be viewed at wileyonlinelibrary.com]
12 RILEY ET AL.

1 3 | CONC LU SION lesions after successfully crossing a CTO with a guidewire. Curr Car-
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