CVIT2020

1. Successful PCI for RCA Chronic Total Occlusion (CTO) with
Knuckle Wire Technique and Reverse CART
Dept. of Cardiology, Tokyo General Hospital, Japan
Yukihiro Yamaguchi, Reiko Tsukahara,
Toshiya Muramatsu, Masatsugu Nakano,
Hideyuki Takimura, Mami Kawano,
Emi Tajima, Yosuke Komatsu
Cardiovascular Intervention and Therapeutics 2020

2. the Japanese Association of
Cardiovascular Intervention and Therapeutics
COI Disclosure
Yukihiro Yamaguchi
The authors have no financial conflicts of interest
to disclose concerning the presentation.

3. LAO 40°
LAO 30°CRA 20°
 Diagnosis: SMI
 Prior intervention:
’19/1 STEMI (seg.7 BP-EES)
‘19/6 SMI (seg.3 CTO failure)
 Coronary risk factor: HT, HL, DM
 eGFR: 42 (mL/min/1.73m2)
 Syntax score: 9
 LVEF 26% (UCG)
 J-CTO score: 3
Cardiovascular Intervention and Therapeutics 2020
Dept. of Cardiology, Tokyo General Hospital, Japan

4. LAO 40°
Dept. of Cardiology, Tokyo General Hospital, Japan
LAO 30°CRA 20°

5. LAO 40°
CB
RV1
CB
①
②
③
①
②
③
4AV
4PD
#3-4 poor image
no calcification
Lesion Angle 150°
Predicted Occl. Length
28mm + <10mm
RV2
RV1 RV2CB
tapered
No calcification
at the CTO site
Tandem
lesion

6. • Prox. Cap : tapered stump
• Occlu. Length : 28mm + <10mm
• Distal vessel : good quality
• Collaterals : good quality
• No calcification, No sharp bend
💡 PLAN
• Trial antegrade - brief
• Retrograde

7. Trial Antegrade approach – brief
For 9 minutes
Dept. of Cardiology, Tokyo General Hospital, Japan
LAO 40°
6Fr Glidesheath slender, 7Fr Launcher AL1.0 SH
Corsair pro 135cm
＋ X-TR
ASAHI GAIA next 1
ASAHI GAIA next 2
ASAHI GAIA next 3
LAO 30°CRA 20°
💡 PLAN
• Switched to Retrograde

8. LAO30°CRA20°
Retro channels
3rd septal 1st septal Apex via diagonal branch
J-channel
score
LAO30°CRA20° LAO30°CRA20°
Dept. of Cardiology, Tokyo General Hospital, Japan
3 (Small, Continuous bends) 4 (Small, Reverse bend, Continuous bends) 5 (Small, Reverse bend, Corkscrew)

9. Retrograde approach ① - 3rd septal branch
6Fr Glide sheath slender
7Fr Launcher EBU 3.5 SH
Caravel MC 150cm, SUOH03, SION black
LAO30°CRA20°
Dept. of Cardiology, Tokyo General Hospital, Japan
LAO30°CRA20°

10. Retrograde approach ① - 3rd septal branch
RAO 30°CRA 20°
Caravel MC 150cm, SUOH03, SION black
Dept. of Cardiology, Tokyo General Hospital, Japan
RAO 30°CRA 20°For 5 minutes

11. Retrograde approach ② - 1stseptal branch
Caravel MC 150cm, SUOH03, SION black
Dept. of Cardiology, Tokyo General Hospital, Japan
RAO 30°CAU 20°
RAO 30°CAU 20°

12. Caravel MC 150cm, SUOH03, SION black
Retrograde approach ② - 1st septal branch
Dept. of Cardiology, Tokyo General Hospital, Japan
RAO 30°CAU 20°
RAO 30°CAU 20° RAO 30°CAU 20°
For 28 minutes

13. Retrograde approach ③ - Apex channel via diagonal branch
LAU 30°
Caravel MC 150cm, SUOH03, SION black
RAO 30°CAU 25°
Dept. of Cardiology, Tokyo General Hospital, Japan

14. LAO 36°CAU 3°
LAO 30°CRA 27°RAO 27°CAU 12°
Retrograde approach ③ - Apex channel via diagonal branch
Caravel MC 150cm, SUOH03, SION black
Dept. of Cardiology, Tokyo General Hospital, Japan
Tip injection
LAO 30°CRA 30°
For 8 minutes

15. RAO 20°CAU 35°
Knuckle Wire Technique
Dept. of Cardiology, Tokyo General Hospital, Japan
ante. retro.

16. LAO 35°
Reverse CART wire technique
SC Balloon 2*10mm
Ultimatebros 3
Dept. of Cardiology, Tokyo General Hospital, Japan
ante.
retro.
Success !!

17. Retrograde approach ③ - Apex channel via diagonal branch
RG3, Extension wire
Dept. of Cardiology, Tokyo General Hospital, Japan
LAO 30°CRA 25°
LAO 30°CRA 25°
SC Balloon 2*15mm

18. Pre-IVUS findings
Navifocus WR
hematoma
Dept. of Cardiology, Tokyo General Hospital, Japan

19. BP-SES 3.5*24 mm, BP-SES 3.5*38 mm, BP-SES 3.5*28 mm, BP-SES 2.5*38mm
NC Balloon 2.75*15mm
Navifocus WR
Stenting, post dilatation and post-IVUS imaging
Dept. of Cardiology, Tokyo General Hospital, Japan
Post-IVUS imaging

20. LAO 10°CRA 35° LAO 30°
Final CAG
Dept. of Cardiology, Tokyo General Hospital, Japan
Procedure time : 231 mims
Radiation : 3.0 Gy
Contract volume : 367 ml

21. Summary
• When two wires, antegrade and retrograde approach, were both in subintimal
space at the randezvous point, the knuckle wire technique was quite effective.
• Straight wire sometimes penetrates a vessel, but knuckled wire advances into the
subintimal space without going outside of the vessel.
• Also, we used the reverse CART, had been standardized, the antegrade balloon
should be as small as possible to avoid bigger dissection (Φ1.5-2.0mm) .
• We should expertise a lot of techniques to take minimizing the risk of complications
such as perforation of collateral channels, the occlusion site.
Dept. of Cardiology, Tokyo General Hospital, Japan