Experts "Live" CTO Workshop 2014 25th Septemper 2014 in Madrid, Spain

1. 10 Key Points to Avoid Major Complications
during CTO PCI
Masahiko Ochiai MD, FACC, FESC, FSCAI
Division of Cardiology and Cardiac Catheterization Laboratories
Showa University Northern Yokohama Hospital, Kanagawa, JAPAN
September 26 (Fri)
Madrid, Spain

2. 1. Definite progress for final success
should be accomplished
within fluoroscopy time of 60mim
(or skin dose of 5 Gy).

3. Antegrade approach: successful antegrade wire cross
Retrograde approach: successful delivery of a retrograde
Corsair through collateral channels
What is the Definite Progress?
Even after the definite progress, more radiation exposure
is mandatory for ballooning and stenting etc.

4. Early transient erythema 2 Gy Hours
Main erythema 6 ~ 10 d
Late erythema 15 ~ 6 – 10 wk
Temporary epilation 3 ~ 3 wk
Permanent epilation 7 ~ 3 wk
Dry desquamation 14 ~ 4 wk
Moist desquamation 18 ~ 4 wk
Secondary ulceration 24 > 6 wk
Ischemic dermal necrosis 18 > 10 wk
Dermal atrophy (1st phase) 10 > 14 wk
Dermal atrophy (2nd phase) 10 > 1 yr
Telangiectasia 10 > 1 yr
Late dermal necrosis >12? > 1yr
Skin cancer Not known 5 yr?
Threshold Skin Entrance Dose for Radiation Dermatitis
King SB, Yeung AC. Interventional Cardiology, 2007, The McGraw-Hill Companies

5. Distribution of the Skin Dose in CTO PCI

6. Back of a Referred Patient after 2nd Attempt of RCA CTO

7. Back of a Referred Patient after 2nd Attempt of LCx CTO

8. 2. Prepare detailed PCI strategies
based on high quality angiogram without panning.

9. Effort AP, DM, HL, Obesity; 57 years, male

10. Effort AP, DM, HL, Obesity; 57 years, male

11. Difference between I.I. System and FPD
Comparison of the effect of circumference distortion
( Left: I.I., Right: FPD)

12. The Benefits of FPD System
Example of Image Processing on FPD system
( Left: Before processing, Right: After processing )

13.  Panning was essential in the era of image intensifiers.
However, current FPD provides clear images of whole
coronary arteries in 6 or 7 inch without panning. If
magnified image is required, modern dicom viewer easily
provides it.
 Detailed information regarding collateral channels or CTO
structure are lost by panning. Panning does more harm
than good. It’s so called masturbation in coronary
angiogram.
 In my institution, panning is strictly prohibited.
Panning

14.  5Fr JL for LCA and 5Fr JR or IM for RCA.
 LCA: 3.5ml/sec, total 5.5ml (Assist TM)
RAO 30 caudal 20, RAO 30, RAO 30 cranial 20
AP cranial 25, AP caudal 25
LAO 45 caudal 25, LAO 45, LAO 45 cranial 15
 RCA: 2.5mll/sec, total 5ml (Assist TM)
LAO 45, AP cranial 25, RAO 30
 Moderate magnification (6inch) without any panning
and collimation
Protocol of Diagnostic CAG at SUNYH

15. 3. Measure ACT and
keep it within your target range.

16. Arterial Access in Retrograde Approach
 Antegrade : 8Fr 45cm long sheath from rt. groin & 8Fr
guiding catheters with side holes.
 Retrograde: 8Fr 45cm long sheath from lt. groin & 7Fr
guiding catheters with side holes.
Blood sample for ACT measurement is taken from the
side arm of the 8Fr sheath every 30min. It should be 
300 sec.

17. 4. Everything (guiding catheters and wires)
should be on the same screen.

18. Retrograde PCI for Ostial LAD CTO
from RCA Originated from Lt. Sinus of Valsalva
8Fr Mach 1
CLS3.5-SH
7Fr Mach1
JL4.0-SH

19. 5. Use guiding catheters  7Fr
without a stiff and tapered tip.

20. ＜A①＞
＜E①＞ ＜E②＞
Distal tip area: 0.603mm2
Distal tip area: 0.320mm2
＜C＞
Distal tip area: 0.957mm2 Distal tip area: 0.730mm2
＜B＞
Distal tip area: 0.717mm2
＜A②＞
Distal tip area: 0.672mm2
＜D＞
Distal tip area: 0.766mm2
200 Times Microscopic Examination
of Various Guiding Catheters

21. 6. Do your best
to identify the entry point into CTO.

22. Effort AP, 71 years, male: Mid LCx CTO
8Fr Brite-tip
XB4.0-SH
6Fr diagnostic
IM

23. Effort AP, 71 years, male: Mid LCx CTO
8Fr Brite-tip
XB4.0-SH
6Fr diagnostic
IM

24. IVUS Examination from the LA Branch

25. IVUS Examination from the LA Branch

26. IVUS Examination from the LA Branch
←
←

27. Gaia 1st with Crusade

28. Crusade was Replaced by IVUS with Trapping Technique

29. Crusade was Replaced by IVUS with Trapping Technique

30. Crusade was Replaced by IVUS
←

31. IVUS was Replaced by Crusade with Trapping Technique
Leaving Gaia 1st as a Landmark on Fluoroscopy

32. Gaia 2nd with Crusade

33. Crusade was Replaced by IVUS with Trapping Technique

34. Crusade was Replaced by IVUS with Trapping Technique

35. Crusade was Replaced by IVUS with Trapping Technique
←

36. IVUS was Replaced by Corsair with Trapping Technique

37. IVUS was Replaced by Corsair with Trapping Technique

38. Gaia 2nd was Stepped Down to Gaia 1st
Gaia 2nd
Gaia 1st

39. Gaia 1st was Advanced Little by Little

40. Gaia 1st was Advanced Little by Little

41. Gaia 1st Reached Distal True Lumen

42. Gaia 1st Reached Distal True Lumen

43. Corsair Passed through the Occlusion
Sion

44. Final Results after Implantation of 3 Xience Xpedition Stents

45. Final Results after Implantation of 3 Xience Xpedition Stents

46. 7. IVUS examination should be done
when an antegrade wire passes the occlusion
into a distal side branch.

47. Effort AP, 74 years, male: Mid LAD CTO

48. Effort AP, 74 years, male: Mid LAD CTO

49. Effort AP, 74 years, male: Mid LAD CTO

50. Effort AP, 74 years, male: Mid LAD CTO

51. Effort AP, 74 years, male: Mid LAD CTO

52. Effort AP, 74 years, male: Mid LAD CTO
7Fr Hyperion
SPB4.0
5Fr diagnostic
IM

53. Stenting to the Proximal LAD
7Fr Hyperion
SPB4.0
5Fr diagnostic
IM
Emerge
2.25mm
Xience Prime
2.5-23mm

54. After Implantation of Xience Prime 2.5-23mm

55. Gaia 2nd with Crusade

56. Parallel Wire Technique with Conquest Pro and Crusade

57. Parallel Wire Technique with Conquest Pro 12
after Re-mounting of Crusade over Conquest Pro

58. If an antegrade wire passes into the side branch of the distal vessel,
IVUS examination should be done
immediately after pre-dilatation with a small balloon.

59. Wire Exchange from Conquest Pro into Sion Blue

60. IVUS Examination after Pre-dilatation with Emerge 1.5mm
Terumo
Navifocus

61. IVUS Examination after Pre-dilatation with Emerge 1.5mm

62. IVUS Examination after Pre-dilatation with Emerge 1.5mm
LAD
Septal

63. IVUS Guided Wiring with Conquest Pro 12

64. IVUS Guided Wiring with Conquest Pro 12

65. IVUS Examination from Diagonal Branch

66. IVUS Examination from Diagonal Branch
LAD
Conquest Pro
12

67. Wire Exchange from Conquest Pro 12 into Sion
Conquest Pro
12
Sion

68. IVUS Examination from Distal LAD

69. IVUS Examination from Distal LAD

70. Final Results after Implantation of 2 Promus Element Stents

71. Final Results after Implantation of 2 Promus Element Stents

72. 8. Use spring coil wires
as your 1st
choice of collateral channel tracking.
Don’t forget to prepare embolic coils in advance.

73. Effort AP, 77 years, female: Proximal RCA CTO Re-try
8Fr Mach1
IM-SH
7Fr Mach1
VL3.5-SH

74. Effort AP, 77 years, female: Proximal RCA CTO Re-try
8Fr Mach1
IM-SH
7Fr Mach1
VL3.5-SH

75. Effort AP, 77 years, female: Proximal RCA CTO Re-try
8Fr Mach1
IM-SH
7Fr Mach1
VL3.5-SH

76. Tip Injection from 150cm Corsair

77. Tip Injection from 150cm Corsair

78. Fielder FC and Corsair were Advanced Alternatively
The patient suddenly complained
of severe chest pain!

79. Perforation of the Epicardial Collateral Channels

80. Perforation of the Epicardial Collateral Channels
To achieve hemostasis at 2 different sites,
2 guiding catheter will be required.

81. 7Fr IM-SH was Replaced by Another 7Fr VL3.5-SH

82. Apex 3.0-20 mm was Inflated at 3 atm.

83. Corsair was Replaced by Excelsior
using Trapping Technique

84. Tip Injection from Excelsior

85. Excelsior was Advanced Further Down
to the Site of Perforation

87. Delivery of the 1st Coil

88. Immediately after the Delivery of the 1st Coil

89. Delivery of the 2nd Coil

90. Immediately after the Delivery of the 2nd Coil

91. Ten Minutes after the Delivery of the 2nd Coil

92. Ten Minutes after the Delivery of the 2nd Coil

93. 9. Knuckle wiring is the safest
when vessel course is not clear at all.

94. Effort AP, 65 years, male: Distal RCA CTO
5Fr diagnostic
IM
5Fr diagnostic
JL5.0

95. Effort AP, 65 years, male: Distal RCA CTO
5Fr diagnostic
IM
5Fr diagnostic
JL5.0

96. Effort AP, 65 years, male: Distal RCA CTO
5Fr diagnostic
IM
5Fr diagnostic
JL5.0

97. Effort AP, 65 years, male: Distal RCA CTO
5Fr diagnostic
IM
5Fr diagnostic
JL5.0

98. MSCT

99. MSCT

100. Tip Injection from Corsair
7Fr Hyperion
SAL1.5-SH
7Fr Hyperion
SPB4.0-SH

101. Repeated Tip Injection from Corsair
7Fr Hyperion
SAL1.5-SH
7Fr Hyperion
SPB4.0-SH

102. Retrograde Channel Tracking with Sion (Cranial 40º)

103. Retrograde Channel Tracking with Sion (Cranial 40º)

104. Bilateral Injection with Corsair

105. Puncture of the Distal Cap with Conquest Pro

106. Retrograde Knuckle Wire Technique with Gaia 2nd
←

107. Retrograde Knuckle Wire Technique with Gaia 2nd

108. Retrograde Knuckle Wire Technique with Gaia 2nd

109. Retrograde Corsair Followed the Knuckled Gaia 2nd

110. Retrograde Corsair Followed the Knuckled Gaia 2nd

111. IVUS Examination from the 2nd RV Branch (Navifocus)

112. Antegrade Wiring with Gaia 3rd and Crusade
←

113. Antegrade Wiring with Gaia 3rd and Crusade
←

114. Antegrade Knuckle Wiring with Gaia 3rd and Corsair

115. Antegrade Wiring with Gaia 3rd and Crusade

116. Pre-dilatation with Kamuui 2.0mm@14atm

117. Successful Reverse CART with Sion

118. Final Results after Implantation of 2 Xience Xpedition Stents

119. Final Results after Implantation of 2 Xience Xpedition Stents

120. 10. Ostial LAD CTO has the highest risk of serious
complications. Stent delivery into LCx should be
guaranteed just in case.

121. Effort AP, 69 years, male: LAD Ostial CTO

122. Effort AP, 69 years, male: LAD Ostial CTO

123. Effort AP, 69 years, male: LAD Ostial CTO

124. Effort AP, 69 years, male: LAD Ostial CTO

125. Effort AP, 69 years, male: LAD Ostial CTO

126. Failed Ad-hoc PCI for LAD Ostial CTO

127. Failed Ad-hoc PCI for LAD Ostial CTO

128. Ad-hoc PCI for Proximal RCA Lesion

129. Final Results

130. Effort AP, 67 years, male: LAD Ostial CTO, Re-try
7Fr Mach1
FL3.5
(lt. radial)
7Fr Mach1
IM-SH
(rt. femoral)

131. Effort AP, 67 years, male: LAD Ostial CTO, Re-try
7Fr Mach1
FL3.5
(lt. radial)
7Fr Mach1
IM-SH
(rt. femoral)

132. I Had Reviewed the Previous Angiogram Frame by Frame

133. Fiedler FC and Corsair were Easily Advanced
through the Septal Channel

134. Tip Injection from Corsair

135. Fielder FC could be Advanced towards Proximal LAD

136. Corsair could be Advanced towards Proximal LAD

137. Corsair could be Advanced towards Proximal LAD

138. Retrograde Wire Crossing with Ultimate 3.0

139. Retrograde Wire Crossing with Ultimate 3.0

140. Retrograde Wire Crossing with Ultimate 3.0

141. IVUS Examination from LCx

142. Ultimate 3.0
Retrograde Lesion Crossing with Corsair
Fielder FC

143. Immediately after Retrograde Wire Externalization with RG3

144. Wiring at Septal Bifurcation
Voyager 2.0mm
14atm
Fiedler FC
with Crusade
Fiedler FC
Finecross
Rinato
Voyager 2.5mm
14atm

145. IVUS Findings at LAD Orifice

146. Positioning of Xience V 3.0-28mm

147. Positioning of Xience V 3.0-28mm

148. Post Dilatation with NC Voyager 3.5mm / 24atm

149. After Post Dilatation with NC Voyager 3.5mm / 24atm

150. After Post Dilatation with NC Voyager 3.5mm / 24atm

151. After Post Dilatation with NC Voyager 3.5mm / 24atm

152. IVUS Findings at LAD Orifice

153. Immediately after Withdrawal of Both Guide Wires from
LAD and LCx

154. Immediately after Withdrawal of Both Guide Wires from
LAD and LCx

155. We should not Loose LCx!

156. IVUS Findings at LCx Orifice

157. Confianza Pro 12gr with Finecross !

158. Immediately after Wire Exchange with Finecross

159. Dilatation with NC Voyager 2.5mm / 12atm

160. Immedeiately after Dilatation with Voyager 2.5mm / 12atm

161. Immedeiately after Dilatation with Voyager 2.5mm / 12atm

162. What should we do next?

163. V-Stenting at LMT Bifurcation (Xience V 3.5-18 / 3.0-18)

164. V-Stenting at LMT Bifurcation (Xience V 3.5-18 / 3.0-18)

165. V-Stenting at LMT Bifurcation (Xience V 3.5-18 / 3.0-18)

166. Kissing Inflation with NC Voyager 3.5mm and Hiryu 3.0mm

167. Immediately after Kissing Inflation

168. Immediately after Kissing Inflation

169. Final Results

170. Final Results

171. Final Results