Live case transmission from Hong Kong to Japan CTO Club 14th June 2019 by Paul Kao.
We had the theme of septal septal collateral channel LAD CTO in this year’s JCTO club APCTO club live case transmission from Hong Kong. Paul tackled this LAD CTO initially via the septal septal collateral but finally successfully wired the lesion via the antegrade with Gaia Next wire.
Live case transmission from Hong Kong to Japan CTO Club 14th June 2019 by Eugene Wu.
Eugene struggled with this 100 mm blunt stump severe calcified and tortuous LAD CTO with blocked LIMA graft requiring Rotablator into the septal branch septal septal collateral reverse CART and finally antegrade wiring of the distal segment of the CTO via a bi-radial approach.
“End Balloon Wiring” (EBW) is a type of Directed reverse CART (what used to be called contemporary reverse CART). Instead of the usual overlapping of the retrograde and antegrade wires, in EBW, we leave a 10 mm gap between the antegrade and retrograde wires. Having inflated the antegrade balloon for reverse CART, we use a directable retrograde wire (such as Gaia wires) to direct the wire towards the end of the inflated balloon. The theory behind this is that wires are forward moving devices and they exert the best penetration force and torque force to targets immediately in front of the wire. Therefore, it is often easy to perform successful reverse CART with end balloon wiring. However, the requirement for doing EBW is that both antegrade and retrograde wires have to be in the intraplaque space and we have to have good control of the retrograde wire. It may seem then that very few cases are suitable for EBW. In this live case, the inventor of EBW, illustrates how to do EBW even in a case where knuckle wiring is used. The operator knuckled the retrograde wire up to 20 mm away from the proximal cap. Then he used an antegrade wire to wire into the intraplaque space in the proximal CTO body and deliberately wire the antegrade wire into the subintimal space after 20 mm. Then he could balloon the antegrade wire and provide a path for the retrograde wire to follow the balloon track from the subintimal space back into the intraplaque space and set up the condition where both antegrade and retrograde wires are intraplaque. Finally, he performed EBW in proximal CTO body successfully.