Advances in Procedural Techniques - Antegrade
James C. Spratt.
There have been many technological advances in antegrade CTO PCI, but perhaps most importantly has
been the evolution of the “hybrid’ approach where ideally there exists a seamless interplay of antegrade wiring, antegrade
dissection re-entry and retrograde approaches as dictated by procedural factors. Antegrade wire escalation with
intimal tracking remains the preferred initial strategy in short CTOs without proximal cap ambiguity. More complex
CTOs, however, usually require either a retrograde or an antegrade dissection re-entry approach, or both. Antegrade
dissection re-entry is well suited to long occlusions where there is a healthy distal vessel and limited “interventional”
collaterals. Early use of a dissection re-entry strategy will increase success rates, reduce complications, and minimise
radiation exposure, contrast use as well as procedural times. Antegrade dissection can be achieved with a knuckle wire
technique or the CrossBoss catheter whilst re-entry will be achieved in the most reproducible and reliable fashion by
the Stingray balloon/wire. It should be avoided where there is potential for loss of large side branches. It remains to be
seen whether use of newer dissection re-entry strategies will be associated with lower restenosis rates compared with
the more uncontrolled subintimal tracking strategies such as STAR and whether stent insertion in the subintimal space
is associated with higher rates of late stent malapposition and stent thrombosis. It is to be hoped that the algorithms,
which have been developed to guide CTO operators, allow for a better transfer of knowledge and skills to increase uptake
and acceptance of CTO PCI as a whole.
Keywords: Antegrade dissection re-entry, chronic total occlusion, knuckle wire, CrossBoss catheter, Stingray balloon.
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