Toyohashi Heart Center IVUS Guidance of CTO Recanalization

Toyohashi Heart Center IVUS Guidance of CTO Recanalization Etsuo Tsuchikane, MD, Ph. D Toyohashi Heart Center, Japan CRT 2010 CTO Forum

DISCLOSURES Etsuo Tsuchikane, MD, Ph. D I have no real or apparent conflicts of interest to report.

Toyohashi Heart Center IVUS Guidance for CTO Recanalization Antegrade Approach A. Examination from proximal side branch 1. Orientation of CTO entrance 2. Checking entry point of the wire B. Examination from subintimal space 1. Penetration from subintimal to true lumen complex Retrograde Approach Reverse CART A. Examination from proximal true lumen 1. Orientation of the retrograde wire 2. Checking vessel size and plaque morphology CRT 2010 CTO Forum

Toyohashi Heart Center Where is the entrance of CTO? CRT 2010 CTO Forum

Toyohashi Heart Center IVUS CRT 2010 CTO Forum

Toyohashi Heart Center Miraclebros 12 CRT 2010 CTO Forum

Toyohashi Heart Center Case: RCA-CTO, Reattempt MIRACLEbros 3 CRT 2010 CTO Forum

Toyohashi Heart Center MIRACLEbros 3 CRT 2010 CTO Forum

Toyohashi Heart Center IVUS CRT 2010 CTO Forum

Toyohashi Heart Center 2 nd wire IVUS CRT 2010 CTO Forum 1 st wire

Toyohashi Heart Center 2 nd wire CRT 2010 CTO Forum 1 st wire

Toyohashi Heart Center MIRACLEbros 6 CRT 2010 CTO Forum

Toyohashi Heart Center IVUS Guided Parallel Wiring Technique 1 st wire in the false channel 2 nd wire in the true channel CRT 2010 CTO Forum

Toyohashi Heart Center CRT 2010 CTO Forum

Toyohashi Heart Center IVUS Guidance for CTO Recanalization Antegrade Approach A. Examination from proximal side branch 1. Orientation of CTO entrance 2. Checking entry point of the wire B. Examination from subintimal space 1. Penetration from subintimal to true lumen Retrograde Approach Reverse CART A. Examination from proximal true lumen 1. Orientation of the retrograde wire 2. Checking vessel size and plaque morphology CRT 2010 CTO Forum

Toyohashi Heart Center Parallel wiring technique Collapsed true lumen CRT 2010 CTO Forum

Toyohashi Heart Center IVUS guided penetration technique False lumen True lumen Guide wire CRT 2010 CTO Forum

Toyohashi Heart Center Case: RCA-CTO CRT 2010 CTO Forum

Toyohashi Heart Center MIRACLEbros 12 with Confianza CRT 2010 CTO Forum

Toyohashi Heart Center IVUS catheter IVUS mirror Wire in the false lumen False lumen CRT 2010 CTO Forum True lumen

Toyohashi Heart Center True lumen 2 nd wire False lumen CRT 2010 CTO Forum Confianza with IVUS

Toyohashi Heart Center Confianza 2 nd Guide wire Confianza CRT 2010 CTO Forum

Toyohashi Heart Center CRT 2010 CTO Forum

Toyohashi Heart Center Case: LAD-CTO (Columbia University) CRT 2010 CTO Forum

Toyohashi Heart Center IVUS 1. 5 mm ballooning CRT 2010 CTO Forum

Toyohashi Heart Center Collapsed true channel Dx CRT 2010 CTO Forum

Toyohashi Heart Center Confianza CRT 2010 CTO Forum

Toyohashi Heart Center IVUS guided wiring CRT 2010 CTO Forum

Toyohashi Heart Center 3 Cyphers (V stenting) CRT 2010 CTO Forum

Toyohashi Heart Center Technical pitfall and drawback of IVUS guided penetration ■ Dilatation of subintimal space is required to deliver an IVUS catheter when necessary. ■ This technique cannot be used if major perforation from subintimal space is already observed. ■ 8 Fr GC is required for simultaneous wiring with IVUS. ■ Stiff wire such as Confianza are required. ■ Multiple stenting is indispensable to fully cover the large subintimal space after successful wiring. CRT 2010 CTO Forum

Toyohashi Heart Center IVUS Guidance for CTO Recanalization Antegrade Approach A. Examination from proximal side branch 1. Orientation of CTO entrance 2. Checking entry point of the wire B. Examination from subintimal space 1. Penetration from subintimal to true lumen Retrograde Approach Reverse CART A. Examination from proximal true lumen 1. Orientation of the retrograde wire 2. Checking vessel size and plaque morphology CRT 2010 CTO Forum

Toyohashi Heart Center Mid RCA CTO, 2 nd Attempt Fielder FC with Corsair CRT 2010 CTO Forum Unsuccessful retrograde crossing

Toyohashi Heart Center Antegrade wiring CRT 2010 CTO Forum 1. 5 ballooning

Toyohashi Heart Center 2. 5 mm ballooning CRT 2010 CTO Forum Unsuccessful reverse CART IVUS examination

Toyohashi Heart Center Retrograde wire CRT 2010 CTO Forum 1 mm

Toyohashi Heart Center 3. 5 mm ballooning CRT 2010 CTO Forum Wire touched balloon!

Toyohashi Heart Center Successful reverse CART CRT 2010 CTO Forum

Toyohashi Heart Center IVUS guidance for CTO-PCI 1. IVUS examination from side branch is easy and effective for branch ostial CTOs. 2. In the antegrade approach, IVUS guided penetration is still the last alternative. 3. In the retrograde approach, IVUS guidance facilitates the reverse CART technique when necessary. CRT 2010 CTO Forum

Toyohashi Heart Center th 12 CTO Club June 11 -12, 2010, Toyohashi, Japan www. cct. gr. jp/ctoclub CRT 2010 CTO Forum