Mr. M, age 55, presented with 8 hours of chest pain. ECG and echo showed normal findings except for inferior wall hypokinesia and EF of 50%. The target vessel for intervention was the proximal right coronary artery (RCA), which showed a visible proximal cap but distal vessel not visible, with Rentrop class 2 collaterals. The document discusses techniques for chronic total occlusion percutaneous coronary intervention including antegrade and retrograde approaches, tools used such as guidewires, balloons, microcatheters and imaging catheters. Challenges of CTO PCI include procedural failure and complications, though successful procedures can improve regional contractility. Experience and suitable anatomy are needed for acceptable outcomes.

2. Mr. M, 55
07/03/23
Chest Pain 8 Hours
hsTrI 4500
ECG- Normal
ECHO- Inferior
wall hypokinesia.
EF – 50%

5. 5

20. 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
20

21. Angiographic
Analysis of CTO
21

23. Hello!
I am Jayden Smith
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presentations.
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23

24. Target Vessel :
 pRCA
 Proximal Cap: Visible
 RCA Dominant
 Distal Vessel: Not
Visible
 Collaterals: Rentrop 2
24

25. Navigating
The Road To
Success In
CTO PCI
25

26. CTO Techniques
 Antegrade wire escalation (AWE),

 Antegrade dissection re-entry (ADR)
 Retrograde wire escalation (RWE)
 Retrograde dissection re-entry (RDR)
26

27. CTO Special Tools
 Guidewires
 Balloons
 Micro Catheters
 Imaging tools/ Catheters
 Lesion preparation : rotational
atherectomy, laser atherectomy
and orbital atherectomy

29. Choice of wire
Instruments
29

30. Wires Balloon Microcatheter Imaging Catheters
F Fc (P) /
Floppy (NP)
NC Fine Cross Navifocus
F XT (P) SC Corsair Opticross
PILOT 50 (P) Cutting Crusade
GAIA 2nd (NP) Scoring Tumpike

31. Choice of wire
31

32. Guidewires
Penetrability
Pushability
Trackability
Torquabilty
Steerability (control)
Bending
Lubricity
32

33. 33

34. 34

36. 36

37. Wires with improved
torquability
37

38. Balloons for CTO
 Very low profile angioplasty
balloons with hydrophilic
coating are available to cross
tight and calcified lesions.
 NC , SC, C, S balloons are
used
38

39. Choice of catheter
39

40. Micro-catheters
 allow for the exchange of guidewires
 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.
 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-
40

41. 41

42. 42

43. 43

44. 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
44

45.  new IVUS
developed by
Boston Scientific
 slightly lower profile
(3.1 Fr)
 transducer which is
somewhat closer to
tip (20 mm)
45

46. 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
46

47.  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
47

48. 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
48

49. 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
49

50. CTO Assessment
of Viability
 MPI
(Inducable
Ischemia)
 CMR
(Segmenta
l Viability)
 Coronary
CTA
 calcifications
>50% of the
cross-sectional
vessel area
 an occlusion
length of >15
mm
 marked vessel
tortuosity
 multiple
occlusions
50

51. 51
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

52. 52
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