Alexander Osiev. Russia
 
The share of CTO is in 7-15%
Success rates Success rate fluctuates from  65  to  7 9% Study % success Puma et al review JACC 1995 65 Kinoshita et al JA...
PCI prosedures
CTO recanalisation success rate
History of CTO recanalization
Разработка специальных проводников
Важнейшие моменты ЧКВ при ХОКА <ul><li>Доступ; </li></ul><ul><li>Проводниковые катетеры; </li></ul><ul><li>Проводники; </l...
Сложные технологии антеградной реканализации ХОКА Техника параллельных проводников ЧКВ под контролем ВСУЗИ Главный недоста...
Стандарты подходов к реканализации ХОКА Визуализация дистального сегмента сосуда; Оптимальная поддержка проводниковым кате...
Реканализация ХОКА через коллатерали <ul><li>Ретроградные техники: </li></ul><ul><li>CART; </li></ul><ul><li>Обычная ретро...
Simple CTO <ul><ul><li>Short Duration of Occlusion </li></ul></ul><ul><ul><li>Post recent AMI </li></ul></ul><ul><ul><li>T...
Difficult CTO <ul><ul><li>> 3 month occlusion </li></ul></ul><ul><ul><li>Non AMI </li></ul></ul><ul><ul><li>CTO Length >15...
Reasons for CTO Failure <ul><li>Technical Success:  77.2% </li></ul><ul><li>Procedural Success:  73.3% </li></ul><ul><li>U...
CTO Strategies Principles of Technique <ul><li>Guiding catheter selection  ( JFL, XB, XBC, AL, ALH) </li></ul><ul><li>Cont...
 
 
 
 
Technical Advancement Conventional Technique •  Bilateral angiography •  Over-the-wire catheter •  Collateral angiography ...
Technical Advancement New Technique •  Parallel wire technique •  Side branch technique •  Sub-intimal re-entry technique ...
Parallel Wire Method with Microcatheters
Side branch dilatation
Subintimal method of recanalization  « Reentry » <ul><li>Previous PTCA philosophy on CTO based on the following principles...
<ul><li>109  patients </li></ul><ul><li>99% successful recanalization of CTO  </li></ul><ul><li>0 – serious complications ...
Retrograde approach <ul><li>techniques: </li></ul><ul><li>Direct retrograde crossing </li></ul><ul><li>Kissing wire </li><...
Direct retrograde crossing
Kissing wire technique
Controlled Antegrade and Retrograde subintimal Tracking ( CART) New concept for CTO recanalization using controlled antegr...
CART  Controlled Anterograde and retrograde subintimal Tracking
Reverse CART
CART  Controlled Anterograde and retrograde subintimal Tracking
CART  Controlled Anterograde and retrograde subintimal Tracking
CART  Controlled Anterograde and retrograde subintimal Tracking
CART  Controlled Anterograde and retrograde subintimal Tracking
CART  Controlled Anterograde and retrograde subintimal Tracking
Snare wire techniques
Snare wire techniques (n= )
Scheme
Snare wire Technique   with antegrade wire passing
Scheme
Snare wire  technique <ul><li>Occlusion coronary artery from ostium, impossibility to set up guiding catheter.  </li></ul>...
New wire type 1  <ul><li>4m ore more </li></ul><ul><li>0,009in </li></ul><ul><li>Good support </li></ul><ul><li>Rotoblatio...
New wire type 2  <ul><li>Double working ends </li></ul><ul><li>Transform retrograde wire into antegrade  </li></ul>
Trapping wire technique Trap tip of the wire by using balloon catheter
Modern devices Safe cross system
 
Modern devices The Crosser system The tip of the CROSSER Catheter mechanically vibrates against the face of the CTO at 20,...
Modern devices Spectranetics
CTO recanalization (2007-2010)
Antegrade approach. Support techniques (1205 patients)
Disadvantages of common support techniques <ul><li>High risk dissection </li></ul><ul><li>Difficult to perform </li></ul><...
The Best Support Retrograde approach.  Coronary Loop Technique.
New wire <ul><li>4m ore more </li></ul><ul><li>0,009in </li></ul><ul><li>Good support </li></ul><ul><li>Rotoblation </li><...
SHOW Deep Technique
SHOW Deep Technique
SHOW Deep Technique
SHOW Deep Technique
SHOW Deep Technique
SHOW Deep Technique
SHOW Deep Technique
SHOW Deep Technique
SHOW Deep Technique
SHOW Deep Technique
SHOW Deep Technique - 561 patients <ul><li>Successful stenting after recanalization of CTO – 99% </li></ul><ul><li>Serious...
SHOW Deep Technique
 
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А.Г. Осиев "Техники реканализации хронических окклюзий коронарных артерий"

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  • Высокий процент успеха связан с использованием современного инструментария и владения спецельных техник в лечении хронических окклюзий коронарных артерий.
  • Методика «Коронарной петли». Под термином «коронарная петля» мы называем коронарный проводник проведенный из проводникового катетера установлено к устью артерии-донора через коллатеральные перетоки и окклюзированную артерию в проводниковый катетер установленный к целевой артерии (рис.14). Мы разделили методику «коронарной петли» на варианты: . Без выведение коронарного проводника из проводникового катетера. Ретроградный проводник проведенный на 20-30см в проводниковый катетер установленный к целевой венечной артерии, прижимается антеградным баллоном внутри катетера, так называемая техника «зажатого проводника» ( GE Jun-bo, ZHANG Feng, GE Lei, QIAN Ju-yingand WANG Hao, 2008 ). Таким образом, создается дополнительная поддержка для проведения ретроградного баллона через окклюзированный участок. . С выведением ретроградного проводника из контрлатерального проводникового катетера наружу. Для выполнения данной методики необходимо коронарный проводник стандартной длинны (190см), сменить на проводник длинной 300см. Проводник проводится в контрлатеральный проводниковый катетер или в восходящую аорту, где захватывается ловушкой типа «гусиная шея» и выводится наружу. Таким образом, создается «коронарная петля», оба конца проводника находятся снаружи. Мягкий кончик проводника аккуратно обрезается, это необходимо для проведения баллон-катетеров или стентов. Методику возможно завершить двумя способами: 3.2.1. С последующим проведением антеградного проводника. 3.2.2. Без проведения аннтеградного проводника.
  • Schematically it can be presented this way
  • Schematically it can be presented this way
  • The SafeCross device (Intraluminal Therapeutics Inc) has a 0.014 inch optical guidewire (Intraluminal wire) that emits near infra-red light (10–30 u resolution). It is placed through a support catheter which helps control guidewire advancement and the guidewire has either a straight or angled tip. Optical coherence reflectometry (OCR) uses the low coherence light transmitted from the 0.007 inch optical fibre incorporated into the tip of the guidewire to reflect from the tissue ahead. Depending on the absorption and scatter pattern present in the reflected signal, the detector can differentiate between plaque and normal artery wall. This information is displayed as a waveform on a screen, which enables the operator to determine the location of the guidewire within the occlusion (fig 7). By avoiding the vessel wall, the risk of perforation or dissection is reduced. Radiofrequency energy (100 ms pulses; 250–500 kHz) is emitted from the tip of the wire that enables it to traverse the tough fibrous cap of refractory CTOs.
  • The Frontrunner catheter (LuMend Inc, Redwood City, California) is a 135 cm long catheter with distal bioptomelike jaws, which can be opened and closed manually to a diameter of 3.0–4.2 mm. It uses controlled blunt microdissection to create a channel through the CTO. The dissection planes are limited to the fibrocalcific plaque, which is more rigid and less stretchable than the vessel adventitia—reducing the risk of vessel perforation.29 30 The latest Frontrunner X39 has a hinged distal tip that can be angled to 25˚ and 36˚, which has improved the ability to navigate tortuous vessels (fig 6). It can be used through a 6 French guide catheter and is supported by a 4 French micro guide catheter (MGC). Once across the CTO, the MGC can be advanced into the distal lumen to function as a conduit for wire exchange.
  • The Crosser system (FlowCardia Inc, California) uses high frequency mechanical vibrations to facilitate the crossing of CTOs by changing the structure and hardness of plaque. It consists of a catheter that is connected to an alternating current power supply via a transducer. The tip of the catheter vibrates at 20 MHz and causes mechanical disruption which aids the passage of a guidewire across a CTO. The catheter tip has an olive shape, a hydrophilic coating, and is 1.1 mm in diameter, compatible with a 6 French guide catheter and a 0.014 inch guidewire. It is available in both rapid exchange and over-the-wire versions. Initial registry data from 25 patients with CTOs resistant to the passage of conventional guidewires has reported a 75% success rate in crossing the occlusion with the Crosser system.32
  • А.Г. Осиев "Техники реканализации хронических окклюзий коронарных артерий"

    1. 1. Alexander Osiev. Russia
    2. 3. The share of CTO is in 7-15%
    3. 4. Success rates Success rate fluctuates from 65 to 7 9% Study % success Puma et al review JACC 1995 65 Kinoshita et al JACC 1995 81 Corco et al CCD 1998 79 Serruys et al TOTAL EHJ 2000 50 Noguchi et al CCI 2000 59 LeFevre et al AJC 53 Suero et al CCI 2003 71 Hoye et al EHJ 65 Overall 68
    4. 5. PCI prosedures
    5. 6. CTO recanalisation success rate
    6. 7. History of CTO recanalization
    7. 8. Разработка специальных проводников
    8. 9. Важнейшие моменты ЧКВ при ХОКА <ul><li>Доступ; </li></ul><ul><li>Проводниковые катетеры; </li></ul><ul><li>Проводники; </li></ul><ul><li>Микрокатетеры (баллонные катетеры); </li></ul><ul><li>ВСУЗИ </li></ul>
    9. 10. Сложные технологии антеградной реканализации ХОКА Техника параллельных проводников ЧКВ под контролем ВСУЗИ Главный недостаток антеградной реканализации – невозможность гарантированного прохождения в дистальный просвет сосуда.
    10. 11. Стандарты подходов к реканализации ХОКА Визуализация дистального сегмента сосуда; Оптимальная поддержка проводниковым катетером; Оптимальный выбор проводника.
    11. 12. Реканализация ХОКА через коллатерали <ul><li>Ретроградные техники: </li></ul><ul><li>CART; </li></ul><ul><li>Обычная ретроградная реканализация: </li></ul><ul><li>Техника целующихся проводников; </li></ul><ul><li>Техника параллельных проводников. </li></ul>Коллатеральные пути: Септальный канал; Эпикардиальный канал; Предсердный канал.
    12. 13. Simple CTO <ul><ul><li>Short Duration of Occlusion </li></ul></ul><ul><ul><li>Post recent AMI </li></ul></ul><ul><ul><li>Tapered entry point </li></ul></ul><ul><ul><li>Functional occlusion TIMI 1 </li></ul></ul><ul><ul><li>CTO length < 15mm </li></ul></ul><ul><ul><li>No bridging collaterals </li></ul></ul><ul><ul><li>No sidebranches </li></ul></ul><ul><ul><li>Non tortuous proximal vessel </li></ul></ul><ul><ul><li>No calcification </li></ul></ul><ul><ul><li>LAD vessel </li></ul></ul><ul><ul><li>Larger vessel diameter > 3mm </li></ul></ul><ul><ul><li>Single vessel disease </li></ul></ul>
    13. 14. Difficult CTO <ul><ul><li>> 3 month occlusion </li></ul></ul><ul><ul><li>Non AMI </li></ul></ul><ul><ul><li>CTO Length >15 mm </li></ul></ul><ul><ul><li>Flush occlusion </li></ul></ul><ul><ul><li>Side branch at entry </li></ul></ul><ul><ul><li>Tortuosity of occlusion/vessel </li></ul></ul><ul><ul><li>Bridging collaterals </li></ul></ul><ul><ul><li>Calcification </li></ul></ul><ul><ul><li>Previously failed CTO attempt </li></ul></ul><ul><ul><li>RCA or LCX vessel </li></ul></ul><ul><ul><li>Smaller diameter vessel </li></ul></ul><ul><ul><li>Multivessel disease </li></ul></ul>
    14. 15. Reasons for CTO Failure <ul><li>Technical Success: 77.2% </li></ul><ul><li>Procedural Success: 73.3% </li></ul><ul><li>Unable to cross with wire: 81% </li></ul><ul><li>Unable to cross with balloon: 11.4% </li></ul><ul><li>Inability to dilate lesion: 7.6% </li></ul>TOAST-GISE JACC 2003: 41;1672-8
    15. 16. CTO Strategies Principles of Technique <ul><li>Guiding catheter selection ( JFL, XB, XBC, AL, ALH) </li></ul><ul><li>Contralateral angiography </li></ul><ul><li>Wire Technique </li></ul><ul><li>IVUS </li></ul><ul><li>DES </li></ul>
    16. 21. Technical Advancement Conventional Technique • Bilateral angiography • Over-the-wire catheter • Collateral angiography • Biplane angiographic equipment • Stepwise guidewire exchange
    17. 22. Technical Advancement New Technique • Parallel wire technique • Side branch technique • Sub-intimal re-entry technique • IVUS-guided recanalization technique • Seesaw wiring technique • etc
    18. 23. Parallel Wire Method with Microcatheters
    19. 24. Side branch dilatation
    20. 25. Subintimal method of recanalization « Reentry » <ul><li>Previous PTCA philosophy on CTO based on the following principles: </li></ul><ul><li> - Wire should be always in the true lumen of the artery </li></ul><ul><ul><li>- Subintimal passage of the wire quite risky and degrades the immediate and remote results of the procedure </li></ul></ul><ul><li>This technique allows for the option pass conduit subintimal, at least part of the occlusion . </li></ul><ul><li>This technique can be used as a continuation of the parallel wires technique or be an independent technical device in case of failure of other </li></ul>
    21. 26. <ul><li>109 patients </li></ul><ul><li>99% successful recanalization of CTO </li></ul><ul><li>0 – serious complications </li></ul>Soft hydrophilic wire deep pass technique
    22. 27. Retrograde approach <ul><li>techniques: </li></ul><ul><li>Direct retrograde crossing </li></ul><ul><li>Kissing wire </li></ul><ul><li>Knuckle-Wire Technique </li></ul><ul><li>Controlled Antegrade and Retrograde Technique (CART) </li></ul>
    23. 28. Direct retrograde crossing
    24. 29. Kissing wire technique
    25. 30. Controlled Antegrade and Retrograde subintimal Tracking ( CART) New concept for CTO recanalization using controlled antegrade and retrograde subintimal tracking : The CART technique. Sumerly JF. ; Tsuchikane E.; Katoh O. The Journal of invasive cardiology. 2006, vol 18, pp. 334-338 
    26. 31. CART Controlled Anterograde and retrograde subintimal Tracking
    27. 32. Reverse CART
    28. 33. CART Controlled Anterograde and retrograde subintimal Tracking
    29. 34. CART Controlled Anterograde and retrograde subintimal Tracking
    30. 35. CART Controlled Anterograde and retrograde subintimal Tracking
    31. 36. CART Controlled Anterograde and retrograde subintimal Tracking
    32. 37. CART Controlled Anterograde and retrograde subintimal Tracking
    33. 38. Snare wire techniques
    34. 39. Snare wire techniques (n= )
    35. 40. Scheme
    36. 41. Snare wire Technique with antegrade wire passing
    37. 42. Scheme
    38. 43. Snare wire technique <ul><li>Occlusion coronary artery from ostium, impossibility to set up guiding catheter. </li></ul><ul><li>Impossibility to lead a balloon through a body of occlusion. </li></ul><ul><li>There is no need for dilatation of septal branch if CART technique is not used. </li></ul><ul><li>There is no need to use antegrade wire passing. </li></ul><ul><li>The most stiff support which one only can imagine is made. </li></ul>
    39. 44. New wire type 1 <ul><li>4m ore more </li></ul><ul><li>0,009in </li></ul><ul><li>Good support </li></ul><ul><li>Rotoblation </li></ul><ul><li>Easy to remove </li></ul>
    40. 45. New wire type 2 <ul><li>Double working ends </li></ul><ul><li>Transform retrograde wire into antegrade </li></ul>
    41. 46. Trapping wire technique Trap tip of the wire by using balloon catheter
    42. 47. Modern devices Safe cross system
    43. 49. Modern devices The Crosser system The tip of the CROSSER Catheter mechanically vibrates against the face of the CTO at 20,000 cycles per second (20kHz) at a stroke depth of approximately 20 microns. This high frequency, low amplitude, longitudinal stroke pulverizes the CTO by mechanical impact, creating a channel through the CTO. Ultrasound Angioplasty. Boston: Kluwer Academic, 1996. 229-240.
    44. 50. Modern devices Spectranetics
    45. 51. CTO recanalization (2007-2010)
    46. 52. Antegrade approach. Support techniques (1205 patients)
    47. 53. Disadvantages of common support techniques <ul><li>High risk dissection </li></ul><ul><li>Difficult to perform </li></ul><ul><li>Rather expensive </li></ul><ul><li>Ischemic complications (deep intubation, anchor with balloon) </li></ul>
    48. 54. The Best Support Retrograde approach. Coronary Loop Technique.
    49. 55. New wire <ul><li>4m ore more </li></ul><ul><li>0,009in </li></ul><ul><li>Good support </li></ul><ul><li>Rotoblation </li></ul><ul><li>Easy to remove </li></ul>
    50. 56. SHOW Deep Technique
    51. 57. SHOW Deep Technique
    52. 58. SHOW Deep Technique
    53. 59. SHOW Deep Technique
    54. 60. SHOW Deep Technique
    55. 61. SHOW Deep Technique
    56. 62. SHOW Deep Technique
    57. 63. SHOW Deep Technique
    58. 64. SHOW Deep Technique
    59. 65. SHOW Deep Technique
    60. 66. SHOW Deep Technique - 561 patients <ul><li>Successful stenting after recanalization of CTO – 99% </li></ul><ul><li>Serious Complication – 1 patient </li></ul>
    61. 67. SHOW Deep Technique

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