IVUS Guidance for CTO Mehrdad Taherioun MD Fellowship

IVUS Guidance for CTO Mehrdad Taherioun MD Fellowship of interventional cardiology Modarres hospital

Ultrasound Principles

Forward-Looking IVUS Under FL-IVUS guidance, the wire is advanced into the true lumen

IVUS IMAGE

Functions of IVUS • • • Makes Sure Vessel Size and Character Decides Stent Size and Position Evaluates Stent Expansion and Apposition Evaluates Dissection at Stent Edge Finds Entry of CTO

CTO‐PCI：current approach Satoru Sumitsuji MD FACC

Antegrade technique

IVUS for wiring an Abrupt Type CTO • Blunt stump with the presence of side branch • Side branch large enough to accommodate the IVUS catheter

Blunt stump with the presence of side branch

Baseline bilateral coronary angiography showing possible entry points

Identify a CTO entry by IVUS • Pull back and push forward with the IVUS catheter around the proximal cap • Keep the IVUS transducer in that position • Using a stiffer wire, or even tapered tip wire, advance the wire tip to the proper location • Torque the wire in the right direction and make several quick pushes with the wire to penetrate the lesion

IVUS transducer at the optimal entry point

Identify a CTO entry by IVUS • Sometimes, parallel wiring technique is useful in this situation • However, the guide-wire may still enter the false lumen

Wire in Sub?

Wire in True!

IVUS guided Reentry technique Step 1: making system for IVUS guided reentry Step 2: dilating lumen for advancing IVUS Step 3: assess and decide strategy Step 4: wiring to get distal true lumen Satoru Sumitsuji MD FACC

Step 1: making system for IVUS guided reentry • GC ≥ 7 Fr or double GC ≤ 6 Fr Advance both IVUS cath and CTO wire with microcatheter

Step 2: dilating lumen for advancing IVUS 1. 5 or 2. 0 mm balloon angioplasty

Step 3: assess and decide strategy • Identify subintimal tracking segment • Reentry point location and direction • Plaque characteristics; calcification

Step 4: wiring to get distal true lumen • Repeat wiring followed by IVUS check until wire get plaque or true lumen • Wire type: usually stiff wire is required

Failure to cross

IVUS guide re-entry of wire

Reentry point location and direction

IVUS in Retrograde approach Reverse CART Technique

Functions of IVUS in retrograde approach • Makes Sure Retrograde Wire Position • Decides Balloon Size for R-CART • Knows Appropriate Site for R-CART

Typical subintimal & intimal image

IVUS Inside CTO

IVUS Findings

Both Wires in Intima Reverse CART Toyohashi Heart Center

Both Wires in Sub-Intima Toyohashi Heart Center

Antegrade Wire in Intima Retrograde Wire in Sub-Intima Toyohashi Heart Center

Antegrade Wire in Sub-Intima Retrograde Wire in Intima Toyohashi Heart Center

Antegrade Wire in Sub-Intima Retrograde Wire in Intima

Penetration Using Confienza Pro 12

summary 1. In an antegrade approach, IVUS could identify entry of CTO located at bifurcation. 2. In a retrograde approach, we could know position of retrograde wire and appropriate balloon size for RCART. 3. IVUS could resolve problems when R-CART dose not work well.

Thank you for your attention