Chapter 4 - Antegrade Wire Escalation: The Foundation of Chronic Total Occlusion Percutaneous Coronary Intervention

Abstract

Antegrade wire escalation is the most easily understood and most widely used chronic total occlusion (CTO) crossing technique and is most appropriate for short occlusions or longer occlusions where a through-and-through microchannel is suspected. Antegrade wire escalation can be divided into seven steps. First, a microcatheter (preferred) or over-the-wire balloon is selected. Second, the microcatheter is advanced to the CTO. Third, a guidewire is selected. Fourth, the guidewire tip is shaped. Fifth, the guidewire is advanced using sliding, drilling, penetration, or a combination of these techniques. Sixth, the wire position is assessed to determine further action. Seventh, if the wire crosses into the distal, true lumen balloon angioplasty and stenting are performed per standard fashion; if the wire enters the subintimal space it is redirected into the distal true lumen using a variety of techniques; if the wire exits the vessel architecture, it is withdrawn and crossing attempts are restarted.