CTO Devices for Crossing, Re-Entry & The Future of Chronic Total Occlusion Treatment

[Dr. Sabeen Dhand]
And then go and finish off the case, right. Where in that algorithm do re-entry devices fit your-- I'll be honest, we do a ton of CLI in my practice. My practice is mainly diabetics and I have a lot of tibial disease, but I have plenty of SFA-Pop disease but using pedal access, I have felt no need to take a re-entry device out because we tend to be able to cross it with a wire and catheter. I want to know for myself and for audiences, what re-entry devices are out there and why should I use them?

[Dr. Jihad Mustapha]
The most commonly available now, two devices that we're all familiar with are the Outback Elite and the Pioneer. There's actually some tips and tricks to them if you're going to use them. The Pioneer, when you've taken it up and over around the horn, you have to always respect it and I tend to use it with a 7 French sheath you can push it through a 6 French sheath is fine, and these they use a 7 French braided sheath because when you go around the horn, you have to actually rotate the needle angle of the Pioneer that is facing down.

Basically, it kind of rides the horn of the aorto-iliac junction, so you can advance it down and smoothly. Otherwise, actually, you will be looking up, so the vector of force will be going away from the contralateral iliac artery. With small rotation, you advance and take it down to where you need it to be and then when your get there, also, be patient because when you rotate in the Pioneer, you have to wait for the forest rotation to get there because the going around the horn, and many of us including me don't do that.

This is one check about the Pioneer. The other thing is please always remember to use a non-hydrophilic wire with it because if you use a hydrophilic wire, you know the consequences of that. That's another thing that's very important. The Outback is similar to the Pioneer. Make sure you always look at the different shafts that come in because you don't want to be going up and over and then you have an 80 centimeter shaft versus 135 and then you want to re-enter at the popliteal then you won't reach.

Again, when you're taking the IVUS catheter of the aortoiliac junction at the horn, the tips can break. For the Pioneer you can lose the value of the IVUS if you break it. For Outback, if the tip bends, then you can lose the functionality of it because it takes it away from the re-entry component or the lumen comes at a distance. These two things for them-- and besides these two, there's not that many out there that actually will give you the good outcome that these two can give you.

When you re-enter, make sure you're not too far in the adventitial space because then you have an angle re-entering and you don't want an angle to [crosstalk].

[Dr. Sabeen Dhand]
That's a good point. The angle can really mess things up. What are some other devices? I believe there's Reflow out there, what are some other ones?

[Dr. Jihad Mustapha]
There's devices that was used in PQ Bypass devices with Limb Flow, but these are not on the market yet. These are re-entered devices, and they'll be in the market soon. There is the Sting Ray which is-- if you're treated just subintimally when it would get back in the lumen and it's more effective when you use it in the tibials, popliteal. It's not very strong, kind of penetrating type of device because it's not a needle, it's a wire that comes out.

The last thing that we use, something called the Wingman, and the Wingman is made by a company called Reflow, and it's got a needle on it. It's 035, 018, and 014. The value of this device in our practice, it's actually cool because you can actually bend it, shape it, and then use it to-- so you don't have that 45-degree re-entry or whatever, you can actually enter it maybe 30 degrees if you want or 15 degrees based on the shape that you make.

[Dr. Sabeen Dhand]
It's designed for like to cross the CTO right? That's what the [crosstalk].

[Dr. Jihad Mustapha]
It's a CTO Catheter.

[Dr. Sabeen Dhand]
It basically centers you and then you can push through, but you've used it in a-- That's neat. You can bend it.

[Dr. Jihad Mustapha]
Yes, because if you shape it, it retain the shape that you put on it, but then with retrograde access and the ability to use two angled catheters, and two angled catheters as we put them next to each other and you start to rotate them back and forth like this, what they do is they break the cap and based on the CTOP analogy of the type of cap you're dealing with, it doesn't matter how complex the cap is, nothing actually crosses the complexity of the CTOP caths better than two catheters come from two different directions on it. They're both in the lumen and they just keep just shaving out--

[Dr. Sabeen Dhand]
I call it like battling of the wires and eventually-- to be honest, we barely even do a car-- it's very rare. I'll put a balloon up and try to make a space. I think, two wires and angled catheters that are lubed and they're going around whatever circumferential subintimal plane you're in, eventually, you're going to connect the two planes, you just have to work at it right?

[Dr. Jihad Mustapha]
We were very fortunate to be able to see under ultrasound. As you know we use ultrasound intra. You can see the catheters actually demolishing the cap and getting closer to each other and you can see sometimes one penetrating the other. If you ask me about the time it takes to do this, it's actually a lot shorter than anything else. Long CTOs right now, no matter how long they are, our time to cross them is less than 10 minutes.

It's not because we're good, it's because we use the technology that is available to us and allows us to see what we're doing and we use the CTOP. You have data, you have technology, all you have to do is tie the two together and then you can cross intraluminal a lot quicker.