This document contains a list of medical terminology and techniques that may be discussed at an upcoming conference over two days. Terms relate to chronic total occlusion interventions and include names of devices, catheters, guidewires, imaging modalities, procedural techniques, definitions, and complications. The list covers topics such as antegrade and retrograde approaches, dissection re-entry techniques, septal surfing, contrast surfing, CART and reverse-CART techniques, the use of IVUS and CT imaging, and device options like the Tornus catheter.

1. Tony Gershlick UKTony Gershlick UK
Basic (CTO) language

2. Words you may hear over the next 2 daysWords you may hear over the next 2 days
CART
(Reverse CART)
ₔModified Reverse CART)
CORSAIR
CROSSBOSS
(Stingray)
IVUS-GUIDED
MSCT
ₔOCT
SEPTAL SURFING
SELECTIVE SEPTAL ENGAGEMENT
SUB-INTIMAL TRACKING
TORNUS
Wedgies
Grenadoplasty
CART
(Reverse CART)
ₔModified Reverse CART)
CORSAIR
CROSSBOSS
(Stingray)
IVUS-GUIDED
MSCT
ₔOCT
SEPTAL SURFING
SELECTIVE SEPTAL ENGAGEMENT
SUB-INTIMAL TRACKING
TORNUS
Wedgies
Grenadoplasty

3. Words you may ALSO hear over the next 2 daysWords you may ALSO hear over the next 2 days
Ok this is going to be difficult to explain
And then the unexpected happened
I was not sure what was going on to be honest
I asked my junior to hold the wire !! !
I’m not 100% sure what actually happened next...
You are going to absolutely love this next bit ....
Mmmm wish I had thought of that ...
And THAT, my friends was the easy part .... “
Ok this is going to be difficult to explain
And then the unexpected happened
I was not sure what was going on to be honest
I asked my junior to hold the wire !! !
I’m not 100% sure what actually happened next...
You are going to absolutely love this next bit ....
Mmmm wish I had thought of that ...
And THAT, my friends was the easy part .... “
私は満足していない 私は手技の進捗に満足していない

4. DEFINITIONS

5. Angiographic success :
as final residual stenosis less than 30% with a TIMI grade
flow ≥ than 2
MACE
cardiac death; acute myocardial infarction
or target vessel revascularisation
all deaths cardiac unless otherwise documented
Non-Q wave infarcts CK-MB > 3 x ULN
TVR repeated revascularisation within the treated vessel
Stent Thrombosis ARC definition
CIN increase of 25% or 0.5 mg/dl in serum creatinine at 48 hrs cf baseline
Angiographic success :
as final residual stenosis less than 30% with a TIMI grade
flow ≥ than 2
MACE
cardiac death; acute myocardial infarction
or target vessel revascularisation
all deaths cardiac unless otherwise documented
Non-Q wave infarcts CK-MB > 3 x ULN
TVR repeated revascularisation within the treated vessel
Stent Thrombosis ARC definition
CIN increase of 25% or 0.5 mg/dl in serum creatinine at 48 hrs cf baseline

6. Antegrade approach
Retrograde approach

7. Prepping the patient
CTO Appropriateness Criteria
Asymptomatic CCS Class I/II CCS Class III/IV
High Risk
Max Rx
U A A
Int. Risk
Max Rx
U U A
Low Risk
Max Rx
U U A
High Risk
No/Min Rx
I U U
Int. Risk
No/Min Rx
I U U
Low Risk
No/Min Rx
I I I
Typical CTO
Visualization
Challenge
Added CTO Road-
map Data from
MSCT

8. Co-Registration
CT
framework
Transformation
Projection
Fluoro
framework

9. You are going to hear a lot about wires and
the techniques
You are going to hear a lot about wires and
the techniques
AnteGAnteG

10. Micro-cathetersMicro-catheters

13. Tornus Catheter
Tornus
Tornus 88Flex
Magnified Tornus Tips
Tsuchikane E. CTO Summit 2010

14. Tip
Distal 20 cm
Proximal
The Asahi Corsair MicrocatheterThe Asahi Corsair Microcatheter
Visibility & Maneuverability –
Tapered Soft Tip & Tungsten Braiding
5mm
Soft tip with
tungsten powder
0.8mm
Platinum
marker coil

15. The Microchannel Technique
Microscopic section through a
CTO with visible microchannels
separated by thin foils
A stiff guidewire (Miracle 3,
Conquest) is advanced proximal to
the fibrous cap and penetrates
through for 1-2 mm
Enlargement of microchannels by
injection of contrast and nitrates
through an OTW balloon and
subsequent passage of a soft
guidewire
AnteGAnteG

16. Parallel wire technique
First wire
Second wire
AnteGAnteG

17. IVUS to identify entry point“IVUS GUIDED
………….”

19. Wedgie

20. ?
?
Antegrade
Retrograde
Dissection Re-Entry
Retrograde

23. Tracks via FAST SPIN technique
•Spin should reduce push required
•Highly torqueable shaft
0.014" guidewire
compatible (OTW)
Atraumatic 3F
rounded distal tip
2.3F shaft profile
The CrossBoss™ CTO Catheter

25. Procedural approach

28. Septal Surfing (George Siannos)
The guidewre (often Sion) advanced rapidly until it
either buckles or advances into the distal target vessel
If it buckles it is withdrawn and re advanced
Probably should avoid epicardial collaterals
Retract sufficiently
Do not push hard
Success higher in proximal straighter collaterals
RAO cranial for initial wiring
RAO caudial for turning into posterior descending

29. Contrast Surfing
3 mls luer lock syringe neat contrast
Aspirate until blood enters syringe
Cine while (gently) injecting
Flush micro-catheter before reengaging guidewire
(stickiness)
Do not pan
RAO caudal for distal part
LAO also

30. CART: controlled antegrade and retrograde
sub-intimal tracking technique
¤ The balloon is kept in place to keep the subintimal space open
¤ The antegrade wire is advanced further along the deflated retrograde
balloon that lies from the subintimal space to the distal true lumen
¤ Dilatation and stent implantation in the usual manner

31. Variations of Reverse CARTVariations of Reverse CART
IVUS –Guided Reverse CART
Allow more precise sizing balloon
and determine if significant recoil
Repeated balloon
Larger Balloon
Snare
Now Guide cath extensions
Punctured Reverse CART
Stiff wire to puncture balloon and deflated balloon withdrawn
Stent Reverse CART
Confluent Balloon Reverse CART
3. Modified Reverse CART = antegrade ballooning + retrograde wirin
But not into sub-intimal space (into side branch)
3. Modified Reverse CART = antegrade ballooning + retrograde wirin
But not into sub-intimal space (into side branch)

33. Tornado®
(Cook Medical)
Embolization Coils Microspheres
Embozene TM
(CeloNova BioSciences)

34. Hybrid CTO PCI Strategy
Hybrid
Strategy
Simple
retrograde
Complex
Antegrade
Complex
Retrograde
Simple
Antegrade

35. Step ApproachAlgorithm (C)
• Ambiguous proximal cap
• Good interventional
collaterals

36. Talking enthusiastically and
excitedly about CTO without the
need to breath
“Lombardiitis”
Inability to find
a theatre cap to fit
“Freddiitis” Smiling charmingly
while indicating your
data are really poor
“Di Mario-ism”

37. Impossible is a word to be
found only in the dictionary
of fools.
Napoleon Bonaparte
Impossible is a word to be
found only in the dictionary
of fools.
Napoleon Bonaparte

44. PTFE Coat
・ Length over all ; 1900
・Coil length ; 160
・Radio paque ; 160
Unit ; (mm)
straigh
t
taper
3010
0.014Inch
Urethan + Hydrophilic Polymer
Coat
0.009Inch
Fielder XT

45. 0.014Inch
Hydrophilic Polymer Coat
PTFE Coat
Rop
e
Unit ; (mm)
・ Length over all ; 1800
・Coil length ; 280
・Radio paque ; 30
Actone
Sion

46. Fielder
FC
Fielder SION SION
blue
XT XT-R ULTIMATE
blos3
1mm
Shaping of the Wire Tip

47. 1. CART = retrograde ballooning + antegrade wiring1. CART = retrograde ballooning + antegrade wiring
2. Reverse CART = antegrade ballooning + retrograde wiring2. Reverse CART = antegrade ballooning + retrograde wiring
2b IVUS guided reverse CART2b IVUS guided reverse CART
Recanalization Using Controlled Antegrade and Retrograde
Subintimal Tracking:
Recanalization Using Controlled Antegrade and Retrograde
Subintimal Tracking:
3. Modified Reverse CART = antegrade ballooning + retrograde wirin
But not into sub-intimal space (into side branch)
3. Modified Reverse CART = antegrade ballooning + retrograde wirin
But not into sub-intimal space (into side branch)

49. O.Dφ0.71
I.Dφ0.46
Tornus Catheter
Tornus-Pro φ0.10㎜×10wires same as Corsair
1350mm
Sleeve300mm 75mm
O.Dφ0.70
I.Dφ0.50
1mm Taper Tip
O.D(φ0.67)
I.Dφ0.41
O.Dφ1.1
Non-Tapered
1350mm
Long Tapered 150mm Sleeve300mm 75mm
Tip O.Dφ0.61
I.Dφ0.41
O.Dφ1.1
Tornus φ0.12㎜×8wires
Tsuchikane E. CTO Summit 2010
Tornus Pro

50. Unpolished shaft
Maximizes the screw effect to pass through
tight lesions
Tornus Catheter
Tornus Pro（Unpolished） Tornus ( Polished）
Features and Benefits of Tornus Pro
Tsuchikane E. CTO Summit 2010

53. Lesion Morphology
Echolucent
plaque
Aneurysm
with
thrombus
Layered
plaque
Incidence
0
10
20
30
Ruptured
plaque
Echolucent Plaque Layered PlaqueRuptured Plaque
88 CTO
lesions
Tsujita K. ACC 2008

54. IVUS Findings: Perforation
Maehara A. CTO Summit 2010

56. Moses JW. CTO Summit 2010
Pre-Procedure
MSCT 3-D Image
Intra-Procedure
Real-Time 2-D
Fluoroscopy
Intra-Procedure C-
Arm CT 3-D
Image
Intervention
Guidance Using
Overlaid Images
Co-Registration
Modalities and Process

57. CT / Fluoro Fusion
Moses JW. CTO Summit 2010
Calcification
Septal
Diagonal branch

58. CTO Toyohashi Heart Center
Slides courtesy of Etsuo Tsuchikane
A B C
D E F
G
Guidewire not jailed: dangerous!!
H I
The STAR Technique

59. ‘Child in Mother’ Technique

61. Case 3 Subintimal Dissection

69. Anchor balloon

70. Procedural approach
XX

72. Or !!!
Balloon
antegrade on
retrograde wire

73. X

76. X

77. Concept of CART technique
- Controlled Antegrade and Retrograde subintimal Tracking
-
Concept of CART technique
- Controlled Antegrade and Retrograde subintimal Tracking
-
¤Simultaneous use of the
antegrade and retrograde
approaches
¤Create a subintimal dissection by
inflating a small (1.5-2.0mm
balloon) over the retrograde wire

78. CART

79. Reverse CART

82. Parallel wire technique
First wire
Second wire