1. 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

2. 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.

3. 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

4. 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

7. Wire Externalization-wiring the guide
Trap prn
Corsair

8. 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)

9. 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

10. Wire Externalization-wiring the guide

11. Wire Externalization-wiring the guide

12. 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

13. Wire Externalization-snaring

14. Wire Externalization-snaring

15. 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

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

17. Wire externalization-snaring
Snare wire and torquer
Loader
Delivery catheter

18. 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

19. Wire exteriorization-snare prep

20. Wire externalization-snaring

21. 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

22. 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

23. Wire externalization-snaring

25. 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

26. Wire externalization in ipsilateral collateral cases

27. 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

28. Wire externalization-threading the antegrade copilot

29. 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

30. Wire externalization-snaring

31. 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.

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