Equipment Utilization in Chronic Total Occlusion Percutaneous Coronary Interventions: Update From the PROGRESS-CTO Registry: An Interview With Emmanouil S. Brilakis, MD, PhD

Dr. Deepak L. Bhatt catches up with Dr. Emmanouil S. Brilakis about his Editor’s 2023 Top 10 article, “Equipment Utilization in Chronic Total Occlusion Percutaneous Coronary Interventions: Update From the PROGRESS-CTO Registry.” Read the article here.

Transcript:

Dr Bhatt: Hello, I'm Dr Deepak Bhatt, Editor-in-Chief of the Journal of Invasive Cardiology, and I'm really lucky to have here with me Dr Manos Brilakis from the Minneapolis Heart Institute. He was a senior author on a paper in the Journal of Invasive Cardiology that was in fact one of the most popular ones last year. This paper looked at the PROGRESS-CTO Registry and provided an update, and I thought that it would be interesting to discuss this paper with Dr. Brilakis. It pertains to equipment utilization and chronic total occlusion. And first of all, let me say welcome.

Dr Brilakis: Thank you, and Deepak it’s a pleasure to be with you.

Dr Bhatt: And before we really get started with the core of the paper, if you could just tell the audience what the PROGRESS-CTO Registry is in the first place.

Dr Brilakis: Absolutely, so PROGRESS-CTO is a multi-center registry. It's mainly based in the US but has now international representation and looks at chronic total occlusion interventions.

There's actually a PROGRESS-CTO, there's another one for bifurcations and complications, but the PROGRESS-CTO is the one we are talking today. And it's trying to assess how things have been evolving in the field of CTO intervention over the last decade or so.

Dr Bhatt: Yeah, that's a nice summary of that. And then perhaps you can just tell the audience specifically what this paper looking at equipment utilization showed.

Dr Brilakis: Absolutely, we have seen some changes over time in terms of what equipment is being used. What this paper did is divided into antegrade and retrograde. And it did show that when we tried to go antegrade, still, the polymer-jacketed guide wires are the ones that are most commonly used. The Fielder XT used to be the most common one, actually the Gladius Mongo, which is a polymer-jacketed, heavy -tip wire, is increasingly being used as well.

But still, we see that the first-choice guide wires for antegrade wiring in CTO remains a polymer -jacketed guide wire. In terms of microcatheters, the classic ones remain the most common ones. We have the Turnpike Spiral, we do have the Corsair, so these are large supportive microcatheters that can be torqued and provide a very strong support. And then in terms of the retrograde approach, what we've seen is a similar trend that we still have a lot of guide wires being used on the retrograde approach. We do have a polymer-jacketed wires as well as the Suoh 03, which is a very soft 0.3-g guide wire that is used quite a bit.

Then we, of course, use the 150-cm microcatheters on the retrograde. But what we're seeing is convergence. More and more people are using similar types of equipment, not necessarily the brand, but the overall type like polymer-jacketed wires, both in the antegrade and the retrograde direction. And again, it's about one-third of the cases were retrograde and the two-thirds of the cases were antegrade.

Dr Bhatt: That's terrific. And there's probably a wide range of people listening in in terms of their familiarity with CTOs and different wiring techniques. Can you tell the audience what the difference is between polymer-jacketed wires and non-polymer-jacketed wires and why that might matter?

Dr Brilakis: Absolutely and this is actually a point still of confusion especially for many of the trainees because they hear the term “hydrophilic” and then they hear also the term “polymer jacket” and those can be mixed up, and the reality is that, yes, the polymer jackets are hydrophilic but to an extreme degree, so they have a very thick very slippery coating that goes all the way to the tip. So, the advantage of that is it can select potential microchannels, it can go in the extra plug or permanently core sub-intimal space and can be knuckled, whereas the Thunder Wire does have a thin hydrophilic coating, but they are not quite as slippery. The disadvantage of the coating, the polymer jacket, is that the feedback is less because the wire tends to go wherever it is pushed. But also, at the same time, the resistance is less.

So, if you have a non-polymer wire, you have more feedback. If you have a polymer-jacketed wire, you have less feedback. Having said that, the polymer-jacketed wires are also generally safer, unless they are pushed outside the end of a side branch. And most of the time, it's less likely to perforate, like the stiffer ones that are non-polymer.

Dr Bhatt: That sounds really good. And maybe for the audience you could just in a nutshell tell them what your favorite algorithm is for antegrade wiring in terms of wire and wire escalation choices. And then the same for retrograde.

Dr Brilakis: Absolutely. We have actually some convergence now. Now there is this global situ algorithm. published a couple of years ago in JACC that kind of outlines the process. But in terms of equipment utilization, I think most operators now are ready to start as long as we understand the proximal cap. So, the gatekeeper is the proximal cap. If it's clear cap, especially if it's tapered and not heavy-cultured, most operators will start with a polymer-jacketed wire. Now whether this is a softer one, it's not like a Fielder XT, Fielder XTA, or Fighter, so it depends on the operator, but most of the we start with the polymer jacket. Some people like to go to the stiffer polymer jackets, like again, the Gladius or the Gladius Mongo, the PILOT 200. Now, if the proximal cap is heavily calcified and is very resistant to penetration, then we typically go with a little heavier tip wire and those are 2 major categories, the middle heaviness, 3 to 6 grams, and these are the Gaias, the Judo wires, and then the more heavy, which are the 12 to 14 grams. This is the Confianza Pro 12, there's the 414, there's the Warrior, so those wires are used when we know exactly where we're going, and there's significant resistance to advancement, for example, in heavy, heavy calcium.

Dr Bhatt: That's terrific. And how about retrograde cases?

Dr Brilakis: So for retrograde cases, we do have quite a variety of equipment, but the concepts are the same. So for retrograde cases, the number one thing we're trying to achieve is to get through the collateral. And then after we do that, the second item in order is to go through the occlusion. So for going through the collateral, we first use a workhorse to get inside the collateral, and then if it's an epicardial, more people will use a Suoh 03, again 0.3 gram very very soft wire, less likely to cause trauma to the vessel and to the collateral. If it is a septal collateral, we can still use the Suoh 03, but some people use the steel black or the regular steel wire.

Now once we get through the collateral and the microcatheter comes through, we typically exchange this wire and we exchange it for something that is a little more penetrating. It's very similar actually to what we use on the antegrade. So either a polymer jacket if it's a long way or if we're going to go extra black and knuckle the guide wire, but if it's a short calcified occlusion, we might have to use a higher tip stiffness wire to get through that initial resistance. But then most of the time we'll switch to a softer polymer-jacket wire to complete the connection and be able to externalize with an R350 or an RG3 guide wire.

Dr Bhatt: That's really helpful practical advice. And it's great to see data coming out from the PROGRESS-CTO Registry letting us know what experienced CTO operators are doing. Any other thoughts you want to share with the audience before we wrap things up?

Dr Brilakis: No, first of all, I want to congratulate you and thank, you know, the Journal of Invasive Cardiology for publishing this manuscript. I think these are very practical information.

We are seeing new equipment coming in. There's a new device coming in, hopefully in the next year. There's some other devices that are in various stages of development. So, is not a static thing. I think it's going to evolve. We're going to have newer and hopefully better equipment to make the procedure faster, more accessible, but also safe.

Dr Bhatt: Fantastic. Well, thank you so much for this nice summary of what I think is a very practical and important paper.

Dr Brilakis: Thank you so much.