2. ▸ Presenter : Dr. Azim Anwar
▸ Phase B Resident, Cardiology.
Chairperson: Prof. MA Muqueet
Professor of Interventional Cardiology
UCC, BSMMU
2
3. What is CTO ?
A chronic total occlusion
(CTO) of a coronary artery is
defined as complete closure
of the vessel lumen for at
least 3 months
TIMI Flow Grade 0
3
25. Balloons for CTO
▸ Very low profile angioplasty balloons with
hydrophilic coating are available to cross tight
and calcified lesions.
▸ NC & SC balloons are used
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30. Imaging catheters
▸ lowest profile catheter (2.6 Fr)
▸ Transducer(eye) is closest to the
tip (9mm) > Easy to look forward
▸ double monorail lumen (1 for the
wire of the IVUS catheter and the
other for directing wire through it
toward the true lumen
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31. ▸ new IVUS developed by
Boston Scientific
▸ slightly lower profile (3.1 Fr)
▸ transducer which is somewhat
closer to tip (20 mm)
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32. CTO Special Tools
▸ IVUS
▸ used to identify the best wire
entry point for penetration of
proximal fibrous cap
▸ to visualize the guidewire to
check intraluminal position
before balloon angioplasty or
stent deployment
▸ used in retrograde procedures
to guide retrograde guidewire
crossing
▸ DES implantation &
Optimization
▸ OCT
▸ Detecting coronary dissection during
PCI
▸ improves stent deployment
▸ to visualize microvessels, the
different layers of the vessel wall,
and even collagen concentration in
coronary arteries
▸ has a 10-fold higher imaging
resolution, but low penetration
▸ does not allow real-time
intracoronary imaging for guidance
of wire crossing
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33. So, what we did ?
▸ Femoral Approach
▸ RCA , Direct, 3.5 X 38 @ 16 ATM (Genoss)
▸ LAD : 1.5 X12 @ 14 ATM , 2 X20 @ 12 ATM
▸ 2.5 x 38 @ 10 ATM (Genoss)
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36. Challenges of CTO PCI
Most challenging procedure in interventional cardiology
Higher periprocedural failure
Higher complication rates
(Plaque embo,Diss…)
Presence of a CTO influences treatment recommendations
A strong predictor against PCI as a treatment strategy
36
37. ▸ Procedural Failure:
▸ Incapacity to pass the lesion
with a guidewire
▸ Failed balloon crossing
▸ Inability to dilate the lesion,
▸ vessel perforation
▸ Predictors of failure:
▸ Increasing age of the occlusion
▸ Small vessel diameter
▸ Presence of calcium or a blunt
stump
▸ Proximal cap ambiguity
▸ Excessive tortuosity
▸ Long occlusion length
▸ Absent visibility of the distal vessel
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38. CTO Revascularization, Is it Worthy ?
▸ successful CTO PCI
increases regional
contractility already 24 h
after the procedure
▸ significant improvements
in segmental wall
thickening
▸ reduction of mean end-
systolic and end-diastolic
volumes
38
39. In A Nutshell…..
▸ CTO PCI in patients with evidence for substantial ischemia in a corresponding
myocardial territory, when performed by an experienced operator ,in case of
adequate clinical indications, and suitable anatomy, with a class-II-B indication
▸ ESC/EACTS/EAPCI guidelines on myocardial revascularization: the task force on
myocardial revascularization
▸ ACCF/AHA/SCAI guideline for percutaneous coronary intervention. A report of the
American College of Cardiology Foundation/American Heart Association Task Force on
practice guidelines and the society for cardiovascular angiography and interventions
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40. CTO Assessment of Viability
▸ MPI (Inducable
Ischemia)
▸ CMR (Segmental
Viability)
▸ Coronary CTA
▸ calcifications >50%
of the cross-sectional
vessel area
▸ an occlusion length of
>15 mm
▸ marked vessel
tortuosity
▸ multiple occlusions
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42. Micro-catheters
▸ The most important function is to allow for the exchange of
guidewires; in addition they provide support to the wire, ensure
positioning of the wire, visualization of distal vessel via injection
of contrast as also negotiation of collaterals and even channel
dilatation. Alternately OTW balloons can be used in some
situations, however, generally micro-catheters have a more
flexible tip (so increased penetrability), wider inner lumen (for
manipulating wire) and the radio-opaque marker is at the tip
(better assessment of distance of the lesion from micro-
catheter).
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43. Take Home Message
To circumvent the difficulties associated with
CTO PCI several specialized devices have been
invented. Each device solves a particular
problem associated with this technique. It is
important to know the properties of individual
hardware, how its specific property can be
used in clinical context and the method of use
of the device
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