This document discusses the use of intravascular ultrasound (IVUS) in chronic total occlusion (CTO) percutaneous coronary interventions (PCI). IVUS can aid in CTO PCI in several ways, including guiding wiring of ostial lesions, sizing balloons for reverse controlled antegrade and retrograde subintimal tracking techniques, guiding re-entry maneuvers, assessing distal vessels, optimizing stent placement, and managing complications. Studies show IVUS guidance may improve outcomes after CTO PCI compared to angiography alone. IVUS provides valuable information on stent expansion and placement that can influence long-term results. While useful, IVUS requires contrast administration and cannot be used for real-time guidance in some techniques like controlled antegrade

1. Intracoronary imaging: when to use, how to
use it and how to interpret the images
Javier Escaned MD PhD FESC
Hospital Clinico San Carlos.
Madrid. Spain.

2. Use of imaging techniques in CTO recanalization
Multi-slice computed
tomography
Intravascular
ultrasound

3. Key imaging patterns in using IVUS in CTOs:
my own terminology
Planets Kidneys Wires

4. How can IVUS aid in CTO´s? A personal list
• IVUS-guided ostial CTO wiring
• Reverse CART balloon sizing
• CART/ADR guidance (no
injections)
• IVUS-guided re-entry
• Assessment of distal vessel
• Optimization of stenting
• Management of complications
• Reduction in contrast use

5. How can IVUS aid in CTO´s? A personal list
• IVUS-guided ostial CTO wiring
• Reverse CART balloon sizing
• CART/ADR guidance (no
injections)
• IVUS-guided re-entry
• Assessment of distal vessel
• Optimization of stenting
• Management of complications
• Reduction in contrast use

6. Basic Principle
1. Choice of Branch
2. Choice of IVUS
3. Choice of CTO wire
IVUS guided wiring

8. Retrograde PCI in ostial LAD CTO

9. IVUS-guided retrograde wire crossing

10. Confianza wire in true lumen and exiting to aorta

11. How can IVUS aid in CTO´s? A personal list
• IVUS-guided ostial CTO wiring
• Reverse CART balloon sizing
• CART/ADR guidance (no
injections)
• IVUS-guided re-entry
• Assessment of distal vessel
• Optimization of stenting
• Management of complications
• Reduction in contrast use

12. Reverse
CART
IVUS imaging in reverse CART

13. Balloon sizing with
IVUS to maximise
subintimal space
and to facilitate
entry of retrograde
wire
Ensuring with IVUS
that retrograde wire
guidewire is within
antegrade lumen
IVUS imaging in reverse CART

14. How can IVUS aid in CTO´s? A personal list
• IVUS-guided ostial CTO wiring
• Reverse CART balloon sizing
• CART/ADR guidance (no
injections)
• IVUS-guided re-entry
• Assessment of distal vessel
• Optimization of stenting
• Management of complications
• Reduction in contrast use

16. • Limited room for
guidewire maneuvering.
• Lack of spatial
orientation.
• Target is a compressed /
collapsed part of the
vessel
Challenges for IVUS-guided re-entry

17. *
*
*
*
Challenges for IVUS-guided re-entry

18. A manuscript from Dr Masahisa Yamane on IVUS and angio for re-entry (2012)
Challenges for IVUS-guided re-entry

19.  Work in the angiographic angulation
showing the largest distance between
IVUS probe and working wire.
 Apply the same principle to
contralateral distal vessel
opacification
 Use a wire with high steerability and
tip control to re-enter
 Correlate your IVUS and angiographic
images as much as possible
Tips for IVUS-guided re-entry

20. Tips for IVUS-guided re-entry

21. How can IVUS aid in CTO´s? A personal list
• IVUS-guided ostial CTO wiring
• Reverse CART balloon sizing
• CART/ADR guidance (no
injections)
• IVUS-guided re-entry
• Assessment of distal vessel
• Optimization of stenting
• Management of complications
• Reduction in contrast use

22. Subintimal track Stented subintimal track
Identifying subintimal track before and
after stenting

24. Angio-IVUS co-registration after
IVUS-guided wiring

26. A
B
C
A
B
C
Assessment of distal vessel

28. • Small distal vessel size with
negative remodelling
predicted by MSCT.
• Identification of CTO ostium
with MSCT.
• Guidance with IVUS.
• Favorable CTO
characteristics(absence of
calcium, no tortuosity).
Learning messages from this case

29. 402 patients with CTOs randomized to IVUS-guided and angiography-guided
groups. Secondarily randomized to ZES or BES.
Kim BK et al Circ Cardiovasc Interv. 2015;8:e002592.
Does IVUS influence outcomes in CTO PCI?

30. Kang J et al PLoS One. 2015 Oct 14;10(10):e0140421
126 patients who underwent DES stenting, and post-PCI IVUS of CTO lesions
IVUS-based post-PCI MLD (<2.4 mm) and stent expansion ratio (≤70%)
values seem to be predictors of ISR in CTO stenting
Does IVUS influence outcomes in CTO PCI?

31. Song L, Kermpaliotis D et al JACC Intv 2017;10:1011–21
Does stenting the subintimal space
influence outcomes in CTO PCI?

32. Song L, Kermpaliotis D et al JACC Intv 2017;10:1011–21
Does stenting the subintimal space
influence outcomes in CTO PCI?

33. How can IVUS aid in CTO´s? A personal list
• IVUS-guided ostial CTO wiring
• Reverse CART balloon sizing
• CART/ADR guidance (no
injections)
• IVUS-guided re-entry
• Assessment of distal vessel
• Optimization of stenting
• Management and prevention of
complications
• Reduction in contrast use

35. Learning messages from this case
• Understanding ambiguous angiographic result of CTO PCI
• Optimization of stenting in complex PCI

36. • Superb visualisation of endoluminal surface and implanted
stents
• Providing valuable clues on long-term results of CTO PCI.
• Limited by the need of contrast administration (avoidance
of CIN in CTO patients is a major issue).
• Cannot be used by guidance without injections (a problem
in CART)
A word on OCT in chronic total occlusions

37. Available at the PCR Bookshop at prconline.com
Coronary Stenosis: Imaging, Structure and Physiology
J Escaned and PW Serruys, editors
Additional information on topics
covered in this presentation