2022/10/27 CCT https://cct.gr.jp/2022/coronary.html

1. Successful two-staged PCI for double CTOs of
the ostial LCX and Completely Occluded long RCA
Dept. of Cardiology, Tokyo General Hospital, Japan
Yukihiro Yamaguchi, Reiko Tsukahara, Toshiya
Muramatsu, Masatsugu Nakano Hideyuki
Takimura, Satoshi Nishio
Yukako Takimura, Mami Kawano
Emi Tajima, Tsuzuki Ippei, Rintaro Taniguchi
Complex Cardiovascular Therapeutics (CCT) 2022
Dept. of Cardiology, Tokyo General Hospital, Japan

2. The authors have no financial conflicts of interest
to disclose concerning the presentation.
Dept. of Cardiology, Tokyo General Hospital, Japan

3. LAO 30° CAU 20°
Diagnosis: SMI, Congestive HF
 Prior intervention: None
 Coronary risk factor: HT, HL, DM
 LVEF 42％ (UCG)
 eGFR: 88 (mL/min/1.73m2)
 J-CTO score: LCX;2, RCA;4
 IMR(index of microvascular resistance) 42
 Syntax score: 28
Dept. of Cardiology, Tokyo General Hospital, Japan LAO 40°
Complex Cardiovascular Therapeutics (CCT)
2022
② mid. RCA (CTO)
① LCX ostium (CTO)

4. Dept. of Cardiology, Tokyo General Hospital, Japan
LAO 30°CAU 20° RAO 40°CAU 20°
LAO 20°CRA 20°
Complex Cardiovascular Therapeutics (CCT)

5. Retro channels via 1st septal branch
J-Channel Score
Dept. of Cardiology, Tokyo General Hospital, Japan
2 (Small)
RAO 40° CAU 25° RAO 40° CAU 20°
Complex Cardiovascular Therapeutics (CCT)

6. ①
②
③
①
②
③
LAD
LCX
LM
①
Predicted Occl. Length = 20mm
Prox. Cap :
Tapered ④
⑤
④
⑤
② ③ ④ ⑤
LCX
No severe calcification
LCX
Cardiac CT findings – LCX
LAO 30° CAU 20°
Dept. of Cardiology, Tokyo General Hospital, Japan

7. RCA
RCA
①
③
① ②
RCA
①
Predicted Occl. Length = 80mm
②③
RV
branch
Cardiac CT findings – RCA
②
③
RV branch
④
④
④
Prox. Cap :
blunt
LAO 40°
Calcification at the entry and the distal site of CTO
180°
Dept. of Cardiology, Tokyo General Hospital, Japan

8. • Prox. Cap : tapered
• Occlu. Length : 20 mm
• Distal vessel : good quality
• Collaterals : none
• No severe calcification
• Straight
💡 PLAN
1st Trial
LCX ostial CTO
LAD #6
2nd Trial
RCA CTO
Dept. of Cardiology, Tokyo General Hospital, Japan
• Prox. Cap : blunt
• Occlu. Length : 80 mm
• Distal vessel : good quality
• Collaterals : good quality
• No severe calcification
• Tortuous and with RV branch
・Antegrade
・Trial antegrade – brief
・Retrograde
▶ LCX ostial CTO ▶ RCA CTO
CTOs strategy
LCX
RCA
Complex Cardiovascular Therapeutics (CCT)

9. Approach: Rt.Radial A.
LCX - Antegrade approach
Dept. of Cardiology, Tokyo General Hospital, Japan
Zizai ™ 135cm
+ XT-R
6Fr Glidesheath slender®, Guide catheter: 7Fr AL1.0 (SH)
Pre-IVUS imaging
AnteOwl WR ™
Tip injection
LAO 30° CAU 30°
LAO 25° CAU 40°
For 8 minutes
Complex Cardiovascular Therapeutics (CCT)

10. Dept. of Cardiology, Tokyo General Hospital, Japan
LCX - pre-dilatation
SCB 1.5*15 mm SCB 2.5*15
mm
SCB 3.0*15 mm
LAO 25° CAU 40°
Complex Cardiovascular Therapeutics (CCT)

11. U-SES 2.5*33 mm
LCX - stenting and post-dilatation
Dept. of Cardiology, Tokyo General Hospital, Japan
Post-IVUS imaging
U-SES 2.5*38 mm
AnteOwl WR ™
KBT SCB 2.5*15 mm
+ stent balloon
KBT SCB 3.0*15 mm
+ SCB 2.5*15 mm
LAO 25° CAU 40°
LAO 25° CAU 40°
Complex Cardiovascular Therapeutics (CCT)

12. Dept. of Cardiology, Tokyo General Hospital, Japan
LAD - pre dilatation, stenting and post-IVUS imaging
Aperta NSE ALPHA ™ 3.5*13
mm
U-SES 4.0*21 mm
Post-IVUS imaging
AnteOwl WR ™
RAO 25° CAU 30°
RAO 25° CAU 30°
Complex Cardiovascular Therapeutics (CCT)

13. Final CAG
Dept. of Cardiology, Tokyo General Hospital, Japan
Procedure time : 71 mins
Radiation : 2.89 Gy
Contrast volume : 277 ml
LAO 20° CAU 30° LAO 15° CAU 45°
Complex Cardiovascular Therapeutics (CCT)

14. Dept. of Cardiology, Tokyo General Hospital, Japan
LAO 40° RAO 30° CRA 20°
Complex Cardiovascular Therapeutics (CCT)

15. Trial Antegrade approach
Dept. of Cardiology, Tokyo General Hospital, Japan
💡 PLAN
Zizai ™ 135cm
+
Switched to Retrograde
Guide catheter: 7Fr AL1.0 (SH), 7Fr EBU3.5 (SH)
XT-R
GAIA NEXT 2nd
For 5 minutes
LAO 40°
Approach: Bi-radial A. 6Fr Glidesheath slender ®
Complex Cardiovascular Therapeutics (CCT)

16. Retrograde approach - septal channel
Dept. of Cardiology, Tokyo General Hospital, Japan
Tip injection
ASAHI CARAVEL MC 150cｍ
＋
SUOH03
Tip injection
RAO 20° CAU 20°
LAO 20° CRA 20°
For 9 minutes
Complex Cardiovascular Therapeutics (CCT)
Tip injection
LAO 20° CRA 15°

17. Zizai + XT-R, GAIA NEXT 2nd
SC Balloon 2*10mm
Dept. of Cardiology, Tokyo General Hospital, Japan
Antegrade approach – 2nd try
CARAVEL + Ultimate bros 3
GAIA NEXT 1st, RG3
ante.
retro.
rCAR
T
Complex Cardiovascular Therapeutics (CCT)
LAO 40°
For 52 minutes
LAO 40°

18. Pre-IVUS findings
subintimal
Dept. of Cardiology, Tokyo General Hospital, Japan
AnteOwl WR ™
RV
branch
RV branch
LAO 30°

19. Dept. of Cardiology, Tokyo General Hospital, Japan
Pre-dilatation
SCB 2.5*15 mm
LAO 30° LAO 15° CRA 20°
Complex Cardiovascular Therapeutics (CCT)

20. U-SES 4.0*38 mm
Stenting
Dept. of Cardiology, Tokyo General Hospital, Japan
U-SES 3.0*50 mm
LAO 35°
Complex Cardiovascular Therapeutics (CCT)
U-SES 2.5*18 mm
KBT SCB 2.0*10 mm
+ stent balloon

21. AnteOwl WR ™
Final-IVUS imaging
Post-dilatation and final IVUS imaging
Dept. of Cardiology, Tokyo General Hospital, Japan
NCB 3.5*15 mm
AnteOwl WR ™
Ostial RCA
LAO 30° CRA 20°
Complex Cardiovascular Therapeutics (CCT)

22. Final CAG
Dept. of Cardiology, Tokyo General Hospital, Japan
Procedure time : 134 mins
Radiation : 3.26 Gy
Contrast volume : 240 ml
LAO 25° CRA 25°
LAO 35°
Complex Cardiovascular Therapeutics (CCT)

23. Discussion ①
a subgroup analysis suggests that patients with
CTO in the LAD may benefit from early additional
CTO PCI.
JACC, 2016, Volume 68, Issue 15, Pages 1622-1632
Dept. of Cardiology, Tokyo General Hospital, Japan
Dept. of Cardiology, Tokyo General Hospital, Japan
LVEDV(ml)
LVEF(%)
In CTO patients with low LVEF, PCI could
represent a safe and effective revascularization
strategy achieving good midterm outcome and
LVEF improvement.
JACC, 2017, Volume 10, Issue 21, Pages 2158-
2170
LVEF improved significantly at 6
month
Complex Cardiovascular Therapeutics (CCT)

24. N Engl J Medicine, 2022 Aug./ESC 2022
Dept. of Cardiology, Tokyo General Hospital, Japan
Among patients with severe ischemic left ventricular systolic dysfunction who received
optimal medical therapy, revascularization by PCI did not result in a lower incidence of death
from any cause or hospitalization for heart failure.
HR 0.99, p=0.96
Optimal medical therapy
PCI
Primary Composite outcome
Death from any causes or hospitalization for heart
failure
Discussion ②
Dept. of Cardiology, Tokyo General Hospital, Japan
Major secondary outcomes
LVEF
PCI
Optimal medical
therapy
Complex Cardiovascular Therapeutics (CCT)
Conclusion

25. Clinical data in our hospital
Study design: a retrospective study
Term: between January 2017 and March 2020
Subject: RCA-CTO (seg. 1-3), 37 cases (the CTO-PCI group: 23 cases; excluding 3 cases PCI-failure, 6 cases follow-up loss,
Optimal Medical Therapy: 14 cases excluding 1 case follow-up loss)
Patients and lesion characteristics:
Dept. of Cardiology, Tokyo General Hospital, Japan
CCT 2019 My Best Case Competition Dept. of Cardiology, Tokyo General Hospital, Japan
Dept. of Cardiology, Tokyo General Hospital, Japan
Complex Cardiovascular Therapeutics (CCT)
CTO-PCI OMT
CTO-PCI OMT
N= 14 N= 12
Lesion
Seg . 1 8 (57.1 % ) 6 (50.0 % )
Seg . 2 1 (7.1 % ) 1 (8 % )
Seg . 3 5 (35.7 % ) 5 (41.2 % )
I SR-CTO 3 (21.4 % ) 2 (16.7)
N=14 N=12
Age 73.1±10.3 75.9±8.6
Male no. (%) 10 (71) 11 (92)
BMI (kg/m2) 22.8±2.9 25.3±2.5
Hypertension no. (%) 5 (36) 11 (92)
Dyslipidemia no. (%) 9 (75) 9 (75)
Diabetes no. (%) 5 (36) 2 (17)
Hemodialysis no. (%) 0 1 (8)
eGFR (mL/min/1.73m2) 63.2±14 50.8±16.8
PAD no. (%) 1 (7) 3 (25)
PMI/ICD・CRT no. (%)/ 1 (7) /0 1 (8) /0
pre LVEF (%) 52.1±15.6 54.1±15.1
pre LVEDV (ml) 115.0±44.5 122.3±40.8

26. Results
p<0.01
Dept. of Cardiology, Tokyo General Hospital, Japan
CCT 2019 My Best Case Competition Dept. of Cardiology, Tokyo General Hospital, Japan
Dept. of Cardiology, Tokyo General Hospital, Japan
Complex Cardiovascular Therapeutics (CCT)
LVEF(%)
20
25
30
35
40
45
50
55
60
80
85
90
95
100
105
110
115
120
125
[%] LVEDV(ml)
[ml]
■ CTO-PCI ■ Optical medical Therapy
Pre Post
All-cause death 0 0
ACS 0 2
Stroke 2 0
Bleeding 1 1
Hospitalization for HF 0 1
ISO 3 -
-16.5%
At 2-year follow-up, LVEDV was significantly
lower in the CTO PCI group. LVEF was not
different.
Post Pre
N=14 N=12
CTO-PCI OMT

27. Summary
• Successful two-stage PCI was performed for double CTO with ostial LCA and
completely occluded long RCA.
• Our clinical data showed a significant reduction in LVEDV in the CTO PCI group, but
no difference in LVEF after RCA-CTO PCI.
Dept. of Cardiology, Tokyo General Hospital, Japan
Complex Cardiovascular Therapeutics (CCT) 2022