Chapters Transcript Video Advanced Re-Entry Techniques Back to Symposium So, this time, I have a very directed talk about crossings, that's what we're gonna discuss. Um, it should always have come before, before the last talk I gave, talking about how to maintain it. But indeed, crossing is, um, like literally the most important thing. So we're gonna talk about a few advanced re-entry techniques. I will be mindful of the time, and I'll be mindful of what you already heard. So, I'm not gonna say the same thing over and over again and waste your time, but I'll focus on the stuff that's important. So, to begin with, again, no disclosures here that are related to this talk, but, you know, when you're doing a procedure endovascularly, literally crossing is the most important thing. If you can't cross, you can't treat, you know, hopefully there'll be a day someday where we can get something where you don't need a wire across and it can just sort of get through calcium, and I'm sure that day will come. But right now, if you can't get a wire across, you're done. And that's why talking about access and different types of access and being facile with it is more and more important these days. Because unfortunately, the type of calcium that we're seeing today is not our grandmother's calcium. It's the calcium that is long, and even if you start through the cap, there's something else down the middle, and, you know, these are cases that you don't really expect to know once you go, go in there, you know, what time period it's gonna take you to get through everything. And then even if you do get through with your wire, what are you gonna do in terms of getting lumino gain and ultimately getting something that'll sustain. So, it can be extremely challenging. And it's definitely the part of the case where you say like, I'm done, and you might have to just stop and move forward and potentially even do a bypass on a patient, if that's even an option these days. So, it is really important and I'm spending a little bit of time belaboring this, that there is a command of the types of crossing catheters that are out there and um the types of crossing techniques that can get you the best result quickly because if you get into a wrong space, like if you get into an uh uh intimate flap or something of that nature, that can be the. Into the case for you. Um, I do a lot of, uh, aortic work, and, you know, when, when we're crossing through those iliacs getting into the aorta and, you know, you get into that subintermost space and it goes all the way up, it's really disconcerting, you know, it's right at that bifurcation, and at that point, you know, using a crossing, uh, catheter like the Pioneer or something like that to get through and sort of pushing forward really can make a whole difference in the case and changed you from doing, um, what you were planning to do to moving to a fem fem if you're not able to get through. So it can make. A big deal. So, to begin with what has already been talked about, Doctor Leslie said about um the wire, the wire is incredibly important first step in thinking about crossing, because when you think about crossing, there are too many things that come into your mind at the same time. You think about the wires, you think about the catheters, you think about the different actual re-entry devices that are out there, but you shouldn't think of it as one hodgepodge. The first thing is, if you can get the wire across, simply, that's the move without anything. Nancy from a cost perspective, from a time perspective, and of course the more stuff you're putting in the patient, it can also be more difficult. The big thing to talk about with the re-entry, uh, devices is that they're difficult. Like Outback, for example, you know, when you're going up and over, you know, it hates the bifurcation. It causes so much drama. So we often had, you know, our, our colleagues that used to do integrated access talk about how wonderful the thing was, and people who do up and over were like, no, it sucks, but we were talking about two different things. And so it is important to know what your re-entry catheters can do. Not just at the tip, but just in general for them getting to the places that they need to go. The other thing about re-entry catheters is that of course you need space. You know, it's great in the aorta. I've got all the space in the world, but if I'm talking about that deep SFA with a lot of calcium, I might not even be able to turn it to get the needle where it needs to be. So things look wonderful on the screen, but in reality, if you can just use that wire to get across, that's the move. So we're gonna spend a bit of time talking about how you can get the wire to go across, depending on the type of wire you're using. And then after that, we'll talk about um going up in steps to get things across. So, first of all, the, like the first panel over here shows you if you just got your wire and you're just pushing, pushing, pushing, even if it's a um glide wire, it doesn't mean that it's necessarily going to do the knuckling that you want. I always tell my residents, um, that a knuckle is great because a knuckle means that you're not gonna be in a dissection plane unless you've already started, of course, in a dissection plane, in which case it just law and you're. Done with the case. Um, but if you can get that knuckle in the right spot, it's wonderful. So sometimes I'll even use a rosin wire, which is 035 and it's got the little, you know, hard tip just to get things started, to get through the cap, so that I can actually push through once I've gotten into the space. Um, the other thing with the wire is that, you know, you can put a balloon down that wire before you touch the wire to the plaque, and then when the balloon blows up, it holds the wire right in the center, so it won't allow it to go. either direction and in this case you can use a little like V18 with the glides, uh, and because that'll go right forward if it makes that knuckling or it does that spiraling and you potentially can just push that uh cap past. So talking about the cap, this is a picture a lot of people know about, but this is just talking about the morphology of it, which we don't do enough of. We do it only here in these meetings, but in reality, who knows what the morphology of the cap. The only thing I want to point out here, just two pearls. One is there are. Microchannels essentially in all plaques. You just have to find them. One of the wires that's not been talked about yet is the Hydro ST. I love it. It's a 014 wire made by Cook, and it does a great job finding those little itty bitty channels. And once you get those little itty bitty, um, wires going past the channels, then you can use a serenity balloon, which is also by Cook, that will just give you a little bit of luminal gain so you can get other stuff down. The second thing to talk about, a lot of people do know this, is that the top. Cap, the more proximal part of it is always harder. I don't know why, but it is. And so if you can come from the bottom, especially if you've, you've jacked up the top, and I usually, I spend my time, you know, with the top, I'd love to do that, whether I prep the foot out or not, it's a pain in the butt to do retrograde, um, access because they have to go get the hockey stick probe and like the resident doesn't really know, at least again in the vascular space, we do all of our cases, unfortunately in the operating room, so it's not a cath lab turnover and stuff. So anything that adds time is a pain. But if I mess up the top, I don't spend a lot of time on that. I very quickly just go to the bottom because again, the bottom is gonna be a softer plaque, and you usually can get through. And then what I'll do is put the sheath right up against the plaque at the top, so my wire can go into the sheath, and then I externalize it up and over all the way through, um, which is relatively easy. A V18 usually is pretty good for that. If I am coming retrograde, I don't put a sheath in the bottom. I'll just puncture retrograde and then put the V18 up it finds. a good spot and then I'll put a CXI crossing catheter over the V18, usually in 018 bareback. And so then at the end, now I've got through and through access and then once I come all the way down, I use a hydro ST to go past wherever I got access so I can just balloon and get control and you're done. So, um, I'm happy to, to talk through any of this if anyone wants to discuss just in terms of the different types of calcified plaque, again, like Eric might be able to say AI. I can see an angiogram and see this. I've never been able to see this. This is not a thing, OK. So, maybe your eyes are better than mine, but in theory, there are different types of plaque, and they do these different things. And if you can tell, obviously, anywhere where there's a space, it's ideal for you to go through. The problem is, of course, that we don't, we talk about plaque as one entity, plaque, plaque, calcium, calcium. It's not entirely true. We were just discussing this yesterday in our board meeting. You know, there's plaque that is rigid, hard calcium. Someone puts cement in the artery, and then there's the Tootsie Pop plaque where it's hard on the outside and inside it's soft. And then there's the plaque that's speckled, that has all the different kinds. Uh, Doctor Tricia Roy, if you want to read her work, talks about these different types of plaques. So the point is wires behave differently. So again, talking about the same thing and saying it'll one size fits all is just. True, but there's no way to tell on angiogram what type of plaque it is. The only thing that could tell you that actually is MRI, and you'd need to be able to read that pretty decently and figure out a pathway. So hopefully the future will be some sort of fusion that will allow you to tell where the wires should go. But in this day and age, without knowing exactly what the type of plaque is, the best thing to do is to get as close to it as possible and find the channel um where. There's a V so that you can get into that space and go from there. Um, I do very much recommend that if you can stay true lumen, you stay true lumen. It makes all the difference in terms of crossing, and it makes all the difference in terms of, um, longevity of whatever you do. But if you have to go subintimo, of course, you have to go. But this is here showing you the different types of, um, and I'm happy to share these slides, by the way, um. Different types of techniques, um, depending on the type of wire that you're using. If you look down at the bottom, I've got the wire type for you specifically and what the specific characteristics of the wire need to be in order to do these things. The danger is that, as was said by Mark, if you use the wrong wire, quote unquote, use a glide wire, you'll easily slip on the side, and then once you've started, you can't get back. It's pretty unforgiving. So, the ideal thing to do is to decide what you want to do before you engage the lesion. Before just shoving at it, and then once you decide that you pick the wire accordingly. So, if you're doing below the knee, focus specifically here on um the occlusion side, um, this is the type of, of, um, gradient that I like to use. You can see increasing cap penetration as you move up. You don't have to use, um, these wires exactly. In fact, you can't, because we all work in institutions where they're like, no, you know, so there's only certain wires that you have available to you on the shelf. But you can find the um the thing that's the closest, you know, like when you order from the supermarket and it says like if they don't have this, what would you like a replacement with, you can do the same with wires. And so if you just have an algorithm, you can actually just go up, but the key is to do it again quickly, fail fast. You don't wanna have um a situation where you're so subinal that you won't be able to get back through. Um, now talking about crossing techniques. So now we've talked about wires. Let's say your wires just are like fail, OK, didn't work. What type of crossing techniques are there? Well, there, there are these 4 types that I'm just gonna bring up to you. Um, the knuckle wire technique we sort of discussed where you push the plaque off a little bit so that you now have a space to come through, and I'll show you all these in a second. Parallel wire techniques are basically where you have two wires, obviously, parallel. You have two wires going down at the same time. You have to upsize your sheath sometimes to do this because you need to put stuff on it afterwards. The cart technique and the reverse cart are the same thing, just one is coming from the top, one is coming from the bottom. Same concept as the wire, uh, the knuckle wire technique, except you have a balloon that's shoving that plaque off of the side. But again, this would have to be plaque that would come off the wall. Like it, nobody really knows like what's the particular type of plaque, but at least these are tech. Techniques that you can potentially use. So, this is the knuckle wire here, um, going through, and I'm gonna thank my very good friend Doctor Tamala, who is, um, the one who, uh, made this video for us. So, here you can see like the knuckle is on the one side. What you're trying to do is get your wire from the top to actually get into the space that you created. Obviously, this requires you to have punctured, in this case, like a digital artery, but this can be done anywhere. The cart technique is conceptually the same, but you're just using the balloon because it's easier and then you can actually poke um at the balloon. You're not gonna puncture it, but you can poke towards it if you get the wire to spin and go in that direction, and then you know exactly where you're gonna be able to get back in and the reverse cart is coming from the top, getting your wire from the bottom if the top didn't work for you, because remember about that plaque being harder. The top than at the bottom. So if you come from the bottom, you're more likely to be able to get through. It's completely possible. You don't have to do any of this drama if you just push your wire and it goes, you don't need to put up something from the top, but usually we've already tried from the top, so never take your stuff out and start coming from the bottom. Leave it because you never know what you're gonna be able to use, um, from the top, depending on where you've actually put your uh wire. Now here is this coming here you can see coming from the AT all the way through again this knuckling and kind of the same spot that was mentioned earlier where we like to puncture where it's a straight shot is kind of a, a, a great place where you can finally get um around and up into your, your main vessel. Now, um, we'll talk a little bit about re-entry devices in a moment. Let me see where's my time. OK, great, a little bit over. Well, sit back, a little bit more to go. So, um, we've got some, uh, uh, um. Some different techniques that are specific to actually using the uh re-entry devices. I'm just gonna show you the re-entry devices very quickly, but the most important thing after we talk about this middle section is that the balloons I find really are beneficial, especiallys Serenity balloons. They slide into all kinds of locations. They're the cook balloons. You take a tiny little Serenity and you really can get it to go anywhere, and it doesn't cause A lot of damage. So if you have a like a little subinal plane, it's not going to make the whole thing dissect. So I really like the double balloon technique because what it does is if you blow up the balloons next to each other, it rips that, uh, intermo, uh, little flap, and now suddenly you have a huge space that you can use. So this is to go from subinal to, um, uh, to true lumen, but even if you're subinal on both sides, because then you. You can just, you know, squeeze it and you can break that little middle and get right through. So, now, talking about the crossing devices, again, I'll just do this in 30 seconds. There are lots of crossing devices. You have to pick the one that you like. The crosser is the BD one. they have a, a new updated crosser that's actually pretty excellent, um, something to, to consider. Again, it depends on what else you have in your, your lab, but basically all the crossing devices do different things and they Mixed different elements. Some are mechanical pushes. Some of them are like, uh, frequency movements. Some are laser, um, and you just have to decide. But again, I think the reason it works sometimes and it doesn't work sometimes is not because of the device at all. It's because of the plaque that you happen to be engaging. Um, this is Cortis makes this, uh, I have not used this one ever, but supposedly the jaws actually spread it apart. I don't know if anyone know, right? Um, this one is kind of conceptually the one. One that is the most common, which is a huge needle that allows you to put a wire through the back of it. The big thing is that you have to turn so that you can point in the direction that you need to go in. Don't be afraid of going right through the wall. I mean, we talk about it, but literally, I've never seen a compartment syndrome from something like this because they're not bleeding anyway, and then ultimately you're gonna blow your balloon up and you're gonna be fine. So feel free to be pretty aggressive trying to get through that plaque, um. Um, I don't know if you guys have ever seen that. And then the laser technique, of course, is pushing the laser all the way up and literally burning and slowly going through. We've got the angiodynamics Ambition BTK trial that's going on right now, um, that, um, is looking at the laser for arthrectomy, but the laser is commercially available and it's something that this really works. Its out nicely is you can just keep moving forward with your wire. Be super careful with the laser. You can't use like, um, hydro ST because that wire will just burn off. You need to use a particular wire that allows you to, to and, and just ask the rep, is this wire OK so that the laser doesn't burn the tip and have it shred inside the patient. Um, and then finally, of course, um, the Phillips, I don't use this anymore. I use just the RN laser, but, um, you can do that contrast blast that was talked, and I'll end with the spinner. This is not a, um. This is not a crossing technique in the classic sense, but I don't know if you know George Adams, who's a wonderful, uh, colleague and mentor. He uses this religiously. The spinner helps you stay true lumen. It's like a gun, and you just load your wire on the back of it. Think of a fancy torque, and you shoot it like you'd shoot a gun, and it spins in like a few rotations to one side and then a few rotations to the other side, and actually drills right through that plaque for you. So, if you don't have this, it's an easy thing to have on the shelf. It's not too expensive, and it really helps you stay true lumen. Thank you very much for your time. Fair enough Published Created by
Content on this site is intended for United States Healthcare Professionals Only
