This document discusses techniques for recanalizing chronic total occlusions (CTOs). It defines a CTO and explains their etiology. Successful recanalization is associated with improved angina and reduced ischemia. Key steps include careful pre-procedure planning, selecting appropriate guidewires and microcatheters, and using techniques like parallel wiring or penetration when standard wiring fails. Expertise is important for high success rates. Proper wire shaping and handling can help avoid subintimal tracking.
Coronary CTO is characterized by heavy atherosclerotic plaque burden within the artery, resulting in complete (or nearly complete) occlusion of the vessel. Although the duration of the occlusion is difficult to determine on clinical grounds, a total occlusion must be present for at least 3 months to be considered a true CTO. Patients with CTO typically have collateralization of the distal vessel on coronary angiography, but these collaterals may not provide sufficient blood flow to the myocardial bed, resulting in ischemia and anginal symptoms. CTO is clinically distinct from acute coronary occlusion, which occurs in the setting of ST-segment–elevation myocardial infarction, or subacute coronary occlusion, discovered with delayed presentation after ST-segment–elevation myocardial infarction. Clinical features and treatment considerations of these entities differ considerably from CTO.
Among patients who have a clinical indication for coronary angiography, the incidence of CTO has been reported to be as high as 15% to 30%. Patients with CTO are referred for angiography because of anginal symptoms or significant ischemia on noninvasive ischemia testing. Patients who are symptomatic will have stable exertional angina resulting from a limitation of collateral vessel flow to meet myocardial oxygen demand with stress. Of patients referred for PCI in clinical trials of CTO PCI, only 10% to 15% of patients are asymptomatic. It is likewise uncommon for patients with CTO to present with an acute coronary syndrome caused by the CTO itself.
Coronary CTO is characterized by heavy atherosclerotic plaque burden within the artery, resulting in complete (or nearly complete) occlusion of the vessel. Although the duration of the occlusion is difficult to determine on clinical grounds, a total occlusion must be present for at least 3 months to be considered a true CTO. Patients with CTO typically have collateralization of the distal vessel on coronary angiography, but these collaterals may not provide sufficient blood flow to the myocardial bed, resulting in ischemia and anginal symptoms. CTO is clinically distinct from acute coronary occlusion, which occurs in the setting of ST-segment–elevation myocardial infarction, or subacute coronary occlusion, discovered with delayed presentation after ST-segment–elevation myocardial infarction. Clinical features and treatment considerations of these entities differ considerably from CTO.
Among patients who have a clinical indication for coronary angiography, the incidence of CTO has been reported to be as high as 15% to 30%. Patients with CTO are referred for angiography because of anginal symptoms or significant ischemia on noninvasive ischemia testing. Patients who are symptomatic will have stable exertional angina resulting from a limitation of collateral vessel flow to meet myocardial oxygen demand with stress. Of patients referred for PCI in clinical trials of CTO PCI, only 10% to 15% of patients are asymptomatic. It is likewise uncommon for patients with CTO to present with an acute coronary syndrome caused by the CTO itself.
How to deal with CALCIFIED CORONARY ARTERY LESIONS .Coronary artery calcification (CAC) is highly prevalent in patients with coronary heart disease (CHD) and is associated with major adverse cardiovascular events. There are two recognized type of CAC—intimal and medial calcification, and each of them have specific risk factors. Several theories about the mechanism of vascular calcification have been put forward, and we currently believe that vascular calcification is an active, regulated process. CAC can usually be found in patients with severe CHD, and this asymptomatic phenomenon make early diagnosis of CAC important. Coronary computed tomographic angiography is the main noninvasive tool to detect calcified lesions. Measurement of coronary artery calcification by scoring is a reasonable metric for cardiovascular risk assessment in asymptomatic adults at intermediate risk. To date, effective medical treatment of CAC has not been identified. Several strategies of percutaneous coronary intervention have been applied to CHD patients with CAC, but with unsatisfactory results. Prognosis of CAC is still a major problem of CHD patients. Thus, more details about the mechanisms of CAC need to be elucidated in order to improve the understanding and treatment of CAC.
rotablation is procedure used in complex pci with heavily calcified lesion for adequate expansion of stent.if used in indicated case and well aware of contraindication is necessary for achieving good results.
Microcatheters for antegrade and retrograde approachEuro CTO Club
Microcatheters for antegrade and retrograde approach
George Sianos, Thessaloniki, Greece
11th Experts Live CTO
The annual Euro CTO meeting
September 13th –14th, 2019 - Berlin, Germany
This is a comprehensive description of coronay lesion assessment from routinely used angiography to advanced imaging modalities like IVUS/OCT including their functional significance by FFR
Chronic Total Occlusions: The Road Less TraveledAllina Health
By M. Nicholas Burke, MD. The use of pioneering percutaneous treatments for chronic total occlusions: indications, limitations, outcomes and current research.
How to deal with CALCIFIED CORONARY ARTERY LESIONS .Coronary artery calcification (CAC) is highly prevalent in patients with coronary heart disease (CHD) and is associated with major adverse cardiovascular events. There are two recognized type of CAC—intimal and medial calcification, and each of them have specific risk factors. Several theories about the mechanism of vascular calcification have been put forward, and we currently believe that vascular calcification is an active, regulated process. CAC can usually be found in patients with severe CHD, and this asymptomatic phenomenon make early diagnosis of CAC important. Coronary computed tomographic angiography is the main noninvasive tool to detect calcified lesions. Measurement of coronary artery calcification by scoring is a reasonable metric for cardiovascular risk assessment in asymptomatic adults at intermediate risk. To date, effective medical treatment of CAC has not been identified. Several strategies of percutaneous coronary intervention have been applied to CHD patients with CAC, but with unsatisfactory results. Prognosis of CAC is still a major problem of CHD patients. Thus, more details about the mechanisms of CAC need to be elucidated in order to improve the understanding and treatment of CAC.
rotablation is procedure used in complex pci with heavily calcified lesion for adequate expansion of stent.if used in indicated case and well aware of contraindication is necessary for achieving good results.
Microcatheters for antegrade and retrograde approachEuro CTO Club
Microcatheters for antegrade and retrograde approach
George Sianos, Thessaloniki, Greece
11th Experts Live CTO
The annual Euro CTO meeting
September 13th –14th, 2019 - Berlin, Germany
This is a comprehensive description of coronay lesion assessment from routinely used angiography to advanced imaging modalities like IVUS/OCT including their functional significance by FFR
Chronic Total Occlusions: The Road Less TraveledAllina Health
By M. Nicholas Burke, MD. The use of pioneering percutaneous treatments for chronic total occlusions: indications, limitations, outcomes and current research.
Despite the advances in wire technology and development of algorithm-driven methodology for chronic
total occlusion (CTO) intervention, there is a void in the literature about the technical aspects of CTO wiring.
The Asia Pacific CTO Club, a group of 10 experienced operators in the Asia Pacific region, has tried to fill this
void with this state-of-the-art review on CTO wiring
Optimize guide catheter support
Fabrice Leroy, Lille, France
11th Experts Live CTO
The annual Euro CTO meeting
September 13th –14th, 2019 - Berlin, Germany
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
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The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
2. CTO-DEFINITION
100% luminaldiameter obstruction without flow in that segment of 3 or more months duration
Presence of TIMI 0 flow within an occluded segment with an estimated occlusion duration of >/= to 3months
Eurointerven 2007 :30:43Heart 2012;98:822-828
A lesion with TIMI 0 flow within the occluded segment
that is judged to be at least 3 months in duration
3. Etiopathogenesis of CTO
1. The late organization and development after an acute occlusion.
2. The progressive occlusion of a long term and high-degree stenosis .
4. Mix of luminal plaque, thrombin,
fibrin, inflammatory cells,
neovascular channels, dense
collagen and calcium deposits.
Core composition correlates with
the CTO age.
Older occlusions- higher
fibrocalcific material (defined as
“hard plaques”)
CTOs -less than one year-less
fibrous materials (defined as “soft
plaque”)
5. No prospective randomized trial.
- In a meta-analysis of 13 observational trials encompassing 7288 pts over a 6 year
follow up ( Joyal D. et al 2010, Am Heart J ), successful recanalization was associated
with significant reduction in residual or recurrent angina. P<0.01).
- Improvement in all three health status domains of Seattle angina Questionarre.
( angina freq., physical limitation, and quality of life) – FACTOR TRIAL 2010.
- A considerable body of evidence suggests that ischemia is associated with adverse
CV events and the reduction of ischemic burden is associated with reduction in
mortality.
WHY TO OPEN UP A CTO ?
6. - In a large study of 10,627 pts undergoing adenosine SPECT, revascularization
compared with medical treatment had greater survival benefit ( absolute
and relative) in patients with inducible ischemia involving more than 10%
of ischemic myocardium (Hachamovitch et al . Circulation 2003)
- In COURAGE nuclear substudy, pts who achieved more than 5% reduction in
ischemic burden with PCI and OMT vs OMT alone had a lower unadjusted risk
of death or MI, particularly if they displayed moderate or severe ischemia
before treatment.
- 2011 ACCF/ AHA / SCAI , PCI of a CTO in patients with appropriate clinical
indications and suitable anatomy is reasonable when performed by operator
with appropriate expertise ( CLASS IIa, LOE B ).
8. J Am Coll Cardiol Intv. 2011;4(2):213-221. doi:10.1016/j.jcin.2010.09.024
J-CTO REGISTRY- (2006-2007),
498 PTS / 528 CTOs
Success rate – 88.6%
Retrograde used in 25.7% with 74.5%
success rate.
Coronary artery perforation- 13.6% in
collateral & 7.2% in CTO artery.
9. PROBABILITY OF ANTEROGRADE GUIDEWIRE
SUCCESS ( J-CTO REG.)
CTO SCORE
0
1
2
3
SUCCESS IN <30 MIN (%)
92.3
58.3
34.8
22.2
10. KEYS FOR SUCCESSFUL CTO RECANALIZATION
1. Proper preprocedure planning and angiographic detail.
2. Appropriate guide selection, ( EBU –LAD , AL 1 – LCX)
3. Appropriate wire selection
4. Judicious use of microcatheters
5. Proper selection of balloons,and other hardware(rotablation if required)
6. Most important is expertise of operator.
7. In japan registry(2002-2008), after introduction of new hardware and techniques, CTO-
PCI success rate is increased upto 90%. (compared to 50-70% in contemporary practice)
11. Preprocedure planning
Paramount importance
Spend time examining diagnostic films & decide on
Approach ,vascular access, guide shape & size
dedicated equipment availability
Occluded & contralateral vessel reviewed in multiple projection frame by frame to
understand complete anatomy
identify proximal & distal cap
vessel course & side branch
calcification
details of collateral circulation
Out of alignment of proximal & distal portion of occlusion with each beat is a sign
of tortuosity inside CTO
EURO CTO club;2012 consensus
12. Guide catheter selection
Percutaneous. Recanalization of Chronic Total Occlusion (CTO) Coronary Arteries: Looking Back and
Moving Forward
Simona Giubilato, Salvatore Davide Tomasello and Alfredo Ruggero Galassi
http://dx.doi.org/10.5772/54079
13.
14. HOW TO INCREASE GUIDE SUPPORT
BEST OPTION FOR STRENGTHENING A GUIDE
1. FIRST best maneuver- put the guide in power position or
deep seat the guide.
2. SECOND best maneuver – Add a second stiffer wire
3. THIRD best maneuver – change to a stronger guide
4. use the balloon anchoring technique
5. insert a smaller straight inside the current guide(mother &
child)
6. remove everything- change the short sheath to a longer one
Advanced interventional cardiology TIPS AND TRICKS-
NGUYEN et al
15. Guide wires
Polymer coated wires – poor tactile feedback, lack of resistance
more chance of subintimal passage
Majority favor – step up approach – moderately increased stiffness(miracle-3)
– switch to greater stiffness &penetration ability, tapered (conquest pro wires)
Some believe –use of stiffer wires initially to cross hard occlusion cap
Rationale: risk of initial dissection minimized, procedure shortened &
simplified with this approach
Kcj 2010
Most common reason for failed CTO PCI- failure of GW to cross
Initial microchannel tracking - soft tapered polymer jacket wire
IVUS guided reentry from subintimal space to true lumen
Tapered High gram stiff wire
Soft polymer jacket wire(FIELDER XT) + microcatheter has improved chance of
antegrade recanalization in first attempt( EURO CTO REGISTRY)
24. ANTEROGRADE WIRING
1. A workhorse, spring coiled wire with a standard working bend is
loaded in an OTW or Micro-catheter.
2. The next wire to use is soft tipped, polymer jacketed, tapered wire
such as Fielder XT. This should be shaped with a 30- 45 degree bend at
1mm.
3. This wire should be manippulated in an attempt to dissect through
occlusion or cross a microchannel.
4. Next wire depends on anatomy :- If occlusion is short and straight-
heavy weight, high puncture force, CTO specific- Confianza pro/
Miracle series. If anatomy unclear or tortuous- Jacketed stiff tipped
such as PILOT 200.
5. Still not, dottering devices- Corsair , Tornus devices.
25. Low profile , trackable, OTW microcatheters - indispensable tool for CTO PCI
Allow ease of wire exchange
It ease torque in the tip response, preventing flexion, kinking, prolapse of
the guide wire, and improving penetration ability
Allows primary & secondary curve adjustment
Dedicated microcatheters – better tip flexibility > OTW balloons
Useful for CTO immediately distal to a bend
Larger inner lumen – reduces friction during wire manipulation
26.
27.
28. Available in 130cm and 150cm lengths, for the antegrade and retrograde approaches
respectively
29. Corsair – HYBRID (support & dilator)
Septal dilator catheter used for the
retrogradeapproach.
Dedicated for selective
engagement of the collateral
channel.
It consists of a tapered tip and
screw head structure, which
reinforces torque transmission for
the guide wire and creates better
back-up support for CTO
penetration.
The Corsair provides superior tip
flexibility which enables smooth
approaches to narrow tortuous
vessels, such as septal channels.
Corsair registry- 93 cto, retrograde, successful channel crossing 96.8%. Successful pci- 84%.
30. TORNUS
Developed to penetrate severe and
hard lesions with greater flexibility
and torquability with a rotational
burrowing advancement manually
manoeuvred by controlled counter-
clockwise rotation. (SCREWING
EFFECT). Platinum marker at the tip.
Useful in situation when wire
crossed the lesion but balloon could
not negotiate the lesion
32. Venture™ Catheter (Velocimed, Minneapolis, Minnesota, USA)- Tip
deflecting catheter, designed to help direct the wire where there are
difficult angles, at bends and in steering the wire away from dissection
planes.
Twin pass (Vascular Solutions, Inc Minneapolis, Minnesota, USA)- dual
access lumen rapid exchange micro-catheter (rapid exchange and over
the wire) which helps the guide wire placement and exchange after
reopening the occlusion and gaining access to different main branches.
Crusade (Kaneka Corporation, Japan- similar design and application of
the Twin pass
35. STRATEGIES FOR PCI OF CTO
DUAL WIRESINGLE WIRE
Soft tapered polymer
jacket wire
Middle weight spring coil
wire
High gram tapered wire
Parallel wire technique
Bilateral retrograde approach
IVUS guided approach
Yamane M Rev Esp Cardiol. 2012.
36. Procedural Steps of Current CTO-PCI
J A C C : C A R D I O V A S C U L A R I N T E R V E N T I O N S , V O L . 4 ,
N O . 9 , 2 0 1 1
S E P T E M B E R 2 0 1 1 : 9 4 1 – 5 1
37.
38. Wire tip shaped as short as possible <45º
Second milder curve - improve maneuverability of wire
Exception - a sharp (>60º) angle with 1 to 2 mm bend based on lumen size, to
navigate the wire from subintimal space back to true lumen( Parallel wire
technique or IVUS guided wiring)
Confianza Pro or Pilot 200 - best suited to this purpose
EuroInterv.2006;2:375-381
How short tip can be bent – depends on length of soldering of spring coil at tip
Usually -1mm, fielder XT -<1mm
Korean Circ J 2010;40:209-215
39. Shaping the wire
1ºbend of 30-45º
1-2mm from tip
Find softest part
2ºbend-10-15º
@3-6mm
Work as a navigator
to orient tip
40. Tip curve should be just larger than lumen diameter
CTO, the lumen diameter = 0 mm
For CTO lesion - Guidewire-tip curve should be very small
Larger curve may hurt the vessel wall during direction control
Hermiller ,SCAI Fellows Course 2009
42. Different methods
Sliding AT proximal cap
Drilling inside CTO
Penetration Distal cap
Short, focal, straight noncalcified lesion – any method
Long tortuous calcified occlusion – wiring tailored to lesion
characteristics
Hard fibrocalcific plaque and tortuosity in CTO- major obstacle
watching the wire tip in relation to lumen in at least 2 orthogonal views
Yamane M Rev Esp Cardiol. 2012
HOW TO AVOID ENTERING THE INTIMA? When trying to cross a curved
segment, avoid positioning the wire at the outer curve of the bend.
3 fundamental elements of wire handling are ROTATING, PUSHING AND
PULLING the wire.
43.
44. ideally there should not be side branches at the site of occlusion and point of entry
should be concave in shape
Simultaneous rotation & probing of lesion
High chance of entering to subintimal space ( tactile response - nil )
SLIDING
Relatively recent occlusion with predominance of microchannels
Extremly low friction wires for picking microchannels used
Recent total, subtotal occlusion ,ISR attempted with this strategy
Long duration – Microchannels replaced by fibrotic tissue
Indian Heart J. 2009; 61:275-280
45. BEWARE bridging collaterals masquerading as microchannel
Polymer sleeved wires NOT forced against resistance, small tip bend, probing with
mild rotation
Soft wires with polymer sleeve – Fielder series/ Whisper/ PT II
46. Drilling Strategy
If discrete entry point present
Technique
short curve(2mm) @45-60º to distal tip
sometimes a secondary curve given proximally
wire advanced with rapid rotational tip and gentle probing
start with MOD stiffness – progressive increase in stiffness(miracle)
Entry to false lumen judged by tactile feel on pulling stiff wire
Reserved for the most skilled and experienced operator
Ineffective with Blunt entry ,heavily calcific & resistant lesions
Indian Heart J. 2009; 61:275-280
47.
48. Penetration
Technique
Pushing stiff wire slowly& gradually – minimum rotation to target direction
Tapered tip wires (confianza pro 9/12)
Softer tip intially progressively stiffer wires
Route determined – various angio or CT findings (not by tactile feel ).
Useful for blunt ,heavily calcific or resistant lesions
Not for CTO with tortuous angulated or bridging collaterals because of
higher chance of perforation
Drilling & penetration – guide support & tip load important
Tip load - success - chance of perforation
50. In the antegrade wire procedure,plaque tracking
should be described as either
1. intimal (loose tissue tarcking)
2. subintimal.
51.
52. “Sigmoid Curve Sign” - to detect subintimal tracking .If the wire is running in a sigmoid
shaped curve with the same width as the vessel diameter, subintimal tracking should
be suspected
53. SENSATION FROM THE FINGERTIPS
.BODY
.GRASPED – false lumen tracking or high
resistance lesion
.SENSATION OF GETTING STUCK WHEN PULLING
BACK - in the intima
.RESISTANCE AT THE TIP OR MOVEMENT DECREASE
– in the false lumen
.EXIT
.FREE MOVEMENT – in the true lumen or in the
extravascular space.
Advanced interventional cardiology- NGUYEN et al
55. 1st wire in false channel
left in situ
2nd stiffer wire advanced parallel to first wire in same path
redirected to enter distal true lumen
main pitfall is wire twisting each other
Support catheter use, appropriate wire selection& handling –essential to avoid wire
twisting
Main purpose : - redirecting a wire inside body of a CTO & puncturing distal fibrous
cap
Important prerequisite – distal vessel visualization
Korean Circ J 2010;40:209-215
56. Visualization of 1st GW & its relative position to 2nd GW using orthogonal view is
essential for success of technique
Adopt the technique before a large subintimal dissection
Chance of successful recanalization by 2nd wire decreases proportionally to the
extent of sub-intimal dissection induced by the first guide-wire.
2nd wire –stiffer with superior torquability
Eg:Miracle12 or Conquest Pro 9/12
57. Check in multiple angiographic views
Advantages
a)Decreased fluro time
b) Reduced contrast
58. See-saw wiring technique
Modification of parallel wire technique
Uses 2 microcatheters or OTW baloons
When first wire fails , 2nd wire with microcatheter or OTW baloon is inserted
Risk – false lumen may enlarge – procedure failure
Japanese operators demonstrated ability to improve wire crossing over
time with this technique(Nakamura& Bae 2008)
59. IVUS Navigated Wiring
IVUS – Depict cross sectional view of coronary tree
IVUS focus on plaque distribution, calcification, reference vessel size & side
branch anatomy
Applicability of IVUS in CTO PCI
1)Side branch method to navigate CTO wire into true lumen from proximal cap .
helps in identify the ambiguous proximal cap.
2)Subintimal rentry from the proximal true lumen
IVUS guided sub intimal rentry – Last resort for getting a subintimal wire into
distal true lumen
Applicable even after losing site of distal vascular bed on angio
60.
61. Importance of wire crossing from true lumen to true lumen
If Subintimal wire crosses without many side branch compromise
Subintimal stenting practical
CTO PCI should be planned to minimize subintimal wiring
Subintimal wiring & stenting – unavoidable in some
Eg: severe fibrocalcific occlusion over a negatively remodelled segment
Larger distal vascular bed – higher chance of TIMI-3 flow
62. WHEN BALLOON NOT
CROSSING CTO
- Deep seat the guide.
- Introduction of second wire into branch proximal to
occlusion to increase support of guide.
- Introduction of wire into true lumen adjacent to first wire
as buddy wire or to increase the dimensions of the channel.
- Larger and more supportive guides.
- Inflation of an angioplasty balloon either in MB or SB to
stabilize the guide.
- Debulking devices.
63. STAR Technique - Subintimal tracking and rentry technique
Used when attempts to recanalize true lumen failed.
0.014 hydrophillic wire with J configration used(whisper, pilot).
Hydrophillic wire pushed through subintimal dissection plane.
When pushed distal to occlusion, J tip should be directed to true lumen in an
attempt to reenter.
Successful in those with previous attempt failed.
Most Ideal vessel for STAR is RCA then LCx. And least ideal
is LAD. Not used now in view of frequent side branch compromise.
High chance of perforation.
Catheter Cardiovasc Interv 2005;64:407–411
Dissection reentry techniques
65. Knuckle wire technique
Polymer jacket wire (fielder XT or pilot-200)manipulated
to create wire loop – advanced subintimally-across CTO –
OTW system advanced to this area- rentry to true lumen
with a stiffer wire or pilot 200
66. BRIDGEPOINT RE-ENTRY SYSTEM
(FDA APPROVED)
CROSSBOSS CATHETER
FAST CTO- 149 pts, success -77% : 42 pts trial(japan)- 67% successful in previous failed cto-pci
68. WHEN TO STOP ANTEGRADE
• Creating a large false lumen.
• Disappearance of the distal vessel course(most likely
because collaterals were sheared off by dissection).
•Reaching limit of dye consumption( typically 600 ml in a
non-diabetic patient with normal renal function.)
•After 2 hours of unsuccessful wiring.(60 min of
flouroscopic time) NGUYEN: TIPS AND TRICKS 4th Ed.
•Excessive patient and operator fatigue.
71. •Initially used after a failed antegrade approach.
• Now used as initial strategy in challenging cases
1) Ostial occlusion 4) Large side branch at proximal cap
2) Long occlusion (>30mm) 5) Severe tortuosity and calcification
3) Without stump 6) Visible continuous collaterals
• Dual femoral arterial access preferred
72. Collateral selection
- Preference - Bypass graft > septal > epicardial
- Selective injection of collateral
- Wiring collateral – achieved with OTW system or dedicated
septal dialator(corsair)
- Contrast injection to assess best connection
- Before injection – aspirate to remove air in microcatheter
- Dripping saline over hub during insertion& removal of guidewire
73. - Hydrophillic polymer jacket wire with <1mm 30-45º tip used
to cross recipient artery
- Fielder FC, Pilot-50, Whisper, Choice PT, Runthrough
- Wiring done in diastole
- Wire should move freely - difficulty to advance – perforation?
- VPC or whipping of wire - RV or LV entry (rarely pericardium)
- Of no consequence if recognized before advancing OTW system
- Collateral dilatation using 1.25-1.5 mm balloon @ 1-2 atm or Corsair
- Epicardial collaterals
size most important factor in wiring success
should never be dilated
-Septal collaterals- tortuosity most imp. factor in wiring success
74.
75. • Manipulation of both antegrade and retrograde wires in CTO until they meet
• Antegrade wire follow channel made by retrograde wire in true lumen of distal vessel
• Simplest form of retrograde technique
• Retrograde wire advanced to distal cap
Acts as a marker of distal true lumen
Serves as a target for antegrade wire
76. Most pure form of retrograde technique(only in 40% retro tech)
Hydrophillic wire advanced to the lesion
Advancement of microcatheter or OTW balloon – additional support
CTO crossed retrogradely using hydrophillic wire or stiffer wire
Manuevers to enhace chance of crossing:-
- Inflating retrograde balloon - coaxial anchor
- Stiffer tapered tip or hydrophillic wires
- IVUS facilitation of retrograde wire to proximal true lumen
77. Controlled antegrade & retrograde subintimal tracking
C A R T
Basic concept –create subintimal dissection with limited extension only at the site of
a CTO
Antegrade wire advanced into CTO then to subintimal space.
Retrograde wire through collateral with microcatheter to distal end of CTO -
into the CTO- then to subintimal space.
Balloon inflation inside CTO using small balloon over the retrograde wire to
subintima.
Balloon inflated inside CTO.
To keep inflated space open, deflated balloon left in subintimal space.
Surmely Jf et alnJ Invasive Cardiol 2006;18:334–338
Limited subintimal tracking (dissection) (LaST) only in CTO segment
79. Reverse CART technique
- Engage a guidewire retrogradely in the distal cap of the CTO
- Another wire anterogradely in the proximal cap of the CTO
- Retrograde wire advanced in subintimal space into CTO lesion
- Subintimal channel is enlarged by anterograde balloon
- Plaque dissection and modification of the lesion
- Retrograde wire advanced to cross the dissection
- Link up with the anterograde wire in proximal true lumen
- Wire externalized (Exchange length)
- Anterograde PCI done
80.
81. KNUCKLE WIRE TECHNIQUE
Best suited for long segment of occlusion
Retrograde wire usually a polymer jacket wire manipulated to form a loop at wire
tip advanced in subintimal space across CTO
Eg: Fielder XT or Pilot-200
Rounded wire loop advanced in subintimal space across CTO without causing
perforation
OTW system advanced to this area followed by attempt to reenter
true lumen using a stiffwire with short bend or hydrophillic wire
Eg: Confianza Pro 12 or Pilot 200
82. Treating lesion after crossing
1 . CTO crossed by antegrade wiring (kissing wire, just marker, CART)
Antegrade CTO PCI can be done
Retrograde balloon can trap antegrade wire to facilitate procedure
2 . Retrograde wire crosses to true lumen
Options : Antegrade wiring
Retrograde wire externalization
ACROSTAK ACROSS CTO BALLOON - smallest lesion entry profile(0.015”), 1.1 mm
DES is preferred in CTO PCI
Viper advance wire preffered for retrograde wire externalisation
83. Complications
Thrombosis and dissection of donor artery
Collateral perforation & occlusion
treated with coil embolization
injection of autologous subcutaneous fat tissue/thrombus
emergency CABG
Entrapment of pci equipment in septal collaterals
Radiation skin injury/CIN/
Subintimal stenting – late coronary aneurysm & stent fractures
85. SafeCross RF Guidewire System
The Safe-Cross radiofrequency guidewire
(IntraLuminal Therapeutics, Carlsbad,
California) combines 3 capabilities: (1)
steerability of a conventional 0.014-in
intermediate-stiffness guidewire, (2) optical
coherence reflectometry to warn the operator
when the wire tip approaches within 1 mm of
the vessel wall, and (3) delivery of
radiofrequency energy pulses to the wire tip
to facilitate passage through an occluded
segment.
NOW FDA APPROVED FOR CORONARY CTO
87. special role in refractory in-stent CTOs wherein the stent serves to
confine the device as it passes through the occlusion
FDA APPROVED for coronary CTO.
Success rate of 56% in series of 107 pts with previous failed cto pci. Perforation rate 0.9-6%
90. UNDER EVALUATION
- Prolonged infusions of fibrinolytic agents
- Collagenase infusion
- ultrasound device(CROSSER, FlowCardia, Inc)- therapeutic ultrasound in
crossing vascular occlusions
- Vibrational angioplasty (Medical Miracles) is a mechanical device that
generates reciprocal and lateral movements in the distal end of a standard
guidewire with frequencies of 16 to 100 Hz
- Ultrasoundguided Pioneer catheter (Medtronic AVE)- Lumen reentry devices
- An alternative approach to CTOs with the use of the Pioneer system also
undergoing investigation is the creation of connections between a coronary
artery and vein (percutaneous in situ coronary vein arterialization [PICVA])
- novel guidance modalities are under development, including forward-looking
ultrasound69,70 and magnetically enabled 3-dimensional wire guidance
94. COMPATIBILITY OF DEVICES INSIDE A 6 FR GUIDING CATHETER.
A) COMBINATION OF FINECROSS AND MONORAIL BALLOON;
B) COMBINATION OF TWO FINECROSS MICROCATHETERS; C)
COMBINATION OF VALET AND MONORAIL BALLOON; D)
COMBINATION OF VALET AND FINECROSS.
95. COMPATIBILITY OF DEVICES INSIDE AN 8 FR GUIDING CATHETER. A)
COMBINATION OF STINGRAY® (BRIDGEPOINT/BOSTON SCIENTIFIC,
NATICK, MA, USA) AND 1.25 MM OTW BALLOON; B) COMBINATION OF
TWO CORSAIRS AND A MONORAIL BALLOON; C) COMBINATION OF TWO
CORSAIRS AND IVUS PROBE; D) COMBINATION OF VENTURE AND
CORSAIR PLUS IVUS PROBE.