Wire Externalization, Snaring and Removal J. Aaron Grantham, MD, FACC Associate Professor of Medicine University of Missouri Kansas City Saint Luke’s Mid America Heart Institute Kansas City, Mo. USA

J. Aaron Grantham, MD Consulting: Abbott Vascular Grant Support: Abbott Vascular. Medtronic, Inc., Asahi Intecc Co. Honoraria: Boston Scientific Corporation, BridgePoint Off-Label: No FDA approved stent for CTO-PCI. Will not recommend one in particular.

Wire Externalization After retrograde lesion crossing a guidewire can be externalized An externalized guidewire provides excellent support for ballooning and stenting long and calcified CTOs Keys steps in externalization

Steps in wiring the antegrade guide After lesion crossing with wire or reverse CART Establish coaxial antegrade guide Advance retrograde crossing wire into antegrade guide Advance channel dilator into antegrade guide (trap the wire in the antegrade guide if needed) Remove the crossing wire and exchange for externalization wire

Wire Externalization-wiring the guide Trap prn Corsair

Wire Externalization Externalization wire characteristics Examples: As long as possible Easy pushability through channel dilator Lubricious, moderately stiff Examples: 335 cm .014” peripheral rotational atherectomy wire (Viper, CSI) 350 cm .012” wire (R350, Vascular Solutions) 330cm .010” purpose built retrograde wire not available in the US (RG 3, Asahi)

Wire Externalization-wiring the guide Sometimes despite coaxial orientation wiring the guide fails Aorto ostial lesions Shepherd crook vessels Poor retrograde guidewire control Vessel caliber much larger than guide Guideliner Snaring

Wire Externalization-wiring the guide

Wire Externalization-wiring the guide

Wire Externalization-wiring the guide After 4-5 passes and perhaps a reshaping or two move quickly to snaring Externalization should not take more than 5 minutes Rather than wasting time trying to wire the guide snaring can save time

Wire Externalization-snaring

Wire Externalization-snaring

Wire Externalization-snaring Snares for the purpose of retrieving devices in vascular spaces exist and are useful in guidewire externalization En Snare 3 snare system 18x30mm tulip snare 6 Fr compatible No need for delivery catheter

Wire externalization-snaring Snaring in Aorta Snaring in Guide/Vessel

Wire externalization-snaring Snare wire and torquer Loader Delivery catheter

Wire Externalization-snaring Pull snare into the loader Advance loader into the antegrade copilot Advance snare to the end of the antegrade guide Begin at the coronary sinuses then try in the ascending aorta Rotate the antegrade guide and spin the snare to catch the exteriorization wire

Wire exteriorization-snare prep

Wire externalization-snaring

Wire Externalization-snaring Always snare the wire you are going to externalize Try to snare on the soft part of the wire if using extra support wires Hard to bend Caution: sweep the wire into the guide to avoid uncoiling the tip Once snared push/pull the wire all the way through and out the antegrade copilot

Wire Externalization-snaring Warning: GENTLY sweep the wire into the guide. Be careful not to unravel the coils Never leave an externalized wire unprotected by a catheter in a collateral Never pull on either end of an externalized wire unless it is protected with a catheter and you can see both guides Never allow antegrade balloons or catheters to meet retrograde balloons or catheters on the same exteriorized guidewire

Wire externalization-snaring

Wire Exteriorization in ipsilateral collateral cases Ipsilateral collaterals pose a unique challenge Wire externalization can be done with an 8 french guide When efficient guide wiring is not possible snaring is not an option Solution is a second “ping pong” guiding catheter

Wire externalization in ipsilateral collateral cases

Wire Externalization-threading the antegrade copilot As the exteriorization wire approaches the antegrade copilot detach the copilot and insert a wire introducer into it. Place your finger over the hub of the antegrade guide and wait for the retrograde wire to tap it. Hook up the copilot by threading the exteriorized wire through the introducer Connect the copilot without flush and continue exteriorizing 20 cm of wire

Wire externalization-threading the antegrade copilot

Externalization final steps after snaring Push/Pull the wire through the antegrade copilot No need for introducer Cut the bent end of the snared wire

Wire externalization-snaring

Wire externalization-removing the wire Balloon and stent with Rx gear After stenting re advance the channel dilator into the antegrade guide Pull both guides well into the aorta Pull the exteriorized wire back from where it came Remove the channel dilator with clockwise rotation. Some advocate leaving a wire in.

Wire externalization-Summary Provides excellent support Wiring the guide Guideliner, snaring Push through Reconnecting antegrade copilot Stenting Removal Guide management