Satoru Sumitsuji – How to apply histologic information in retrograde approach without IVUS nor CT

2. 【Invited Lecture & PCI Workshop Map】 2013 (33) January Taiwan February Egypt・Indonesia・USA March Hong Kong・Taiwan・China April Malaysia・Italy・Philippines・Bangladesh May UAE・KSA・Taiwan・China・Hong Kong June July Malaysia August China・Korea September Colombia・Switzerland・France・UAE October Indonesia・USA November Kuwait・Oman・Malaysia・Thailand・China x2 December Singapore・Taiwan 2014 (39) January Korea・Singapore・China February India・UAE・Hong Kong・USA March Hong Kong・China April Taiwan・Bangladesh・Korea May Egypt・China・Kuwait June Jordan・Taiwan July August USA・Egypt・Jordan・UAE September USA・China October Malaysia・Kuwait・UAE・Korea・China November China・Egypt・Colombia・UAE・Indonesia December Bangladesh・Singapore・Kuwait・UAE・Indonesia・ Tunisia

3. Histological Key Points in RETRO  Intimal Plaque / Subintima  Loose Tissue

4. Basic Understandings Intimal Plaque Media = Subintima Adventitia EEL: External Elastic Lamina IEL: Internal Elastic Lamina

5. Basic Understandings Intimal Plaque Media = Subintima False Lumen True Lumen

6. Basic Understandings Intimal Plaque Media = Subintima False Lumen True Lumen

7. Basic Understandings Intimal Plaque Media = Subintima = Intramural hematoma in IVUS False Lumen True Lumen

8. Basic Understandings Intimal Plaque Media = Subintima = Intramural hematoma in IVUS False Lumen True Lumen

9. Basic Understandings Intimal Plaque Media = Subintima = Intramural hematoma in IVUS Collapsed True Lumen False Lumen

10. Terminology with IVUS Outside CTO Intimal Plaque Subintima Subintima Intimal Plaque

11. Terminology with IVUS Inside CTO Intimal Plaque Subintima Intimal Plaque Subintima

12. Feature of Subintima Sumitsuji et al. JACC Intv 2011; 9:941– 51

13. Subintimal tracking in antegrade Sumitsuji et al. JACC Intv 2011; 9:941– 51

14. Subintimal tracking in antegrade Sumitsuji et al. JACC Intv 2011; 9:941– 51

15. Key to success in antegrade approach is “intimal plaque tracking” Sumitsuji et al. JACC Intv 2011; 9:941– 51

16. Subintimal tracking in retrograde Sumitsuji et al. JACC Intv 2011; 9:941– 51

17. IVUS : Retrograde Antegrade wire Intimal Plaque Subintima Retrograde wire Intimal Plaque Retrograde wiring & Antegrade ballooning or Direct puncture Retrograde wiring & More proximal connection or Original CART Subintima Antegrade ballooning or More distal connection Antegrade ballooning A R A R A R A R

18. IVUS : Retrograde Antegrade wire Intimal Plaque Subintima Retrograde wire Intimal Plaque Retrograde wiring & Antegrade ballooning or Direct puncture Retrograde wiring & More proximal connection or Original CART Subintima Antegrade ballooning or More distal connection Antegrade ballooning A R A R A R A R PP SP PS SS

19. IVUS : Retrograde Antegrade wire Intimal Plaque Subintima Retrograde wire Intimal Plaque Antegrade ballooning and Retrograde wiring Retrograde wiring and More proximal connection Subintima Antegrade ballooning or More distal connection Antegrade ballooning A R A R A R A R SS

20. IVUS : Retrograde Antegrade wire Intimal Plaque Subintima Retrograde wire Intimal Plaque Antegrade ballooning and Retrograde wiring Retrograde wiring and More proximal connection Subintima Antegrade ballooning or More distal connection Antegrade ballooning A R A R A R A R

22. IVUS : Retrograde Antegrade wire Intimal Plaque Subintima Retrograde wire Intimal Plaque Antegrade ballooning and Retrograde wiring Retrograde wiring and More proximal connection Subintima Antegrade ballooning or More distal connection Antegrade ballooning A R A R A R A R PS

24. IVUS : Retrograde Antegrade wire Intimal Plaque Subintima Retrograde wire Intimal Plaque Antegrade ballooning and Retrograde wiring Retrograde wiring and More proximal connection Subintima Antegrade ballooning or More distal connection Antegrade ballooning A R A R A R A R DISTAL

25. IVUS : Retrograde Antegrade wire Intimal Plaque Subintima Retrograde wire Intimal Plaque Antegrade ballooning and Retrograde wiring Retrograde wiring and More proximal connection Subintima Antegrade ballooning or More distal connection Antegrade ballooning A R A R A R A RDISTAL DISTAL

26. IVUS : Retrograde Antegrade wire Intimal Plaque Subintima Retrograde wire Intimal Plaque Antegrade ballooning and Retrograde wiring Retrograde wiring and More proximal connection Subintima Antegrade ballooning or More distal connection Antegrade ballooning A R A R A R A RDISTAL DISTAL

27. IVUS : Retrograde Antegrade wire Intimal Plaque Subintima Retrograde wire Intimal Plaque Retrograde wiring & Antegrade ballooning or Direct puncture Retrograde wiring and More proximal connection Subintima Antegrade ballooning or More distal connection Antegrade ballooning A R A R A R A R PP

30. IVUS : Retrograde Antegrade wire Intimal Plaque Subintima Retrograde wire Intimal Plaque Antegrade ballooning and Retrograde wiring Retrograde wiring and More proximal connection Subintima Antegrade ballooning or More distal connection Antegrade ballooning A R A R A R A R PUNCTURE!

31. IVUS : Retrograde Antegrade wire Intimal Plaque Subintima Retrograde wire Intimal Plaque Retrograde wiring & Antegrade ballooning or Direct puncture Retrograde wiring and More proximal connection Subintima Antegrade ballooning or More distal connection Antegrade ballooning A R A R A R A R PROXIMAL

32. IVUS : Retrograde Antegrade wire Intimal Plaque Subintima Retrograde wire Intimal Plaque Retrograde wiring & Antegrade ballooning or Direct puncture Retrograde wiring and More proximal connection Subintima Antegrade ballooning or More distal connection Antegrade ballooning A R A R A R A R PROXIMAL PROX

33. IVUS : Retrograde Antegrade wire Intimal Plaque Subintima Retrograde wire Intimal Plaque Retrograde wiring & Antegrade ballooning or Direct puncture Retrograde wiring and More proximal connection Subintima Antegrade ballooning or More distal connection Antegrade ballooning A R A R A R A R PROX PROXIMAL

34. IVUS : Retrograde Antegrade wire Intimal Plaque Subintima Retrograde wire Intimal Plaque Antegrade ballooning and Retrograde wiring Retrograde wiring & More proximal connection or Original CART Subintima Antegrade ballooning or More distal connection Antegrade ballooning A R A R A R A R SP

35. IVUS : Retrograde Antegrade wire Intimal Plaque Subintima Retrograde wire Intimal Plaque Antegrade ballooning and Retrograde wiring Retrograde wiring & More proximal connection or Original CART Subintima Antegrade ballooning or More distal connection Antegrade ballooning A R A R A R A R

36. IVUS : Retrograde Antegrade wire Intimal Plaque Subintima Retrograde wire Intimal Plaque Antegrade ballooning and Retrograde wiring Retrograde wiring & More proximal connection or Original CART Subintima Antegrade ballooning or More distal connection Antegrade ballooning A R A R A R A R 1 PROXIMAL

37. IVUS : Retrograde Antegrade wire Intimal Plaque Subintima Retrograde wire Intimal Plaque Antegrade ballooning and Retrograde wiring Retrograde wiring & More proximal connection or Original CART Subintima Antegrade ballooning or More distal connection Antegrade ballooning A R A R A R A R PROXIMAL PROX PROX

38. IVUS : Retrograde Antegrade wire Intimal Plaque Subintima Retrograde wire Intimal Plaque Antegrade ballooning and Retrograde wiring Retrograde wiring & More proximal connection or Original CART Subintima Antegrade ballooning or More distal connection Antegrade ballooning A R A R A R A R PUNCTURE! PROXIMAL PROX PROX

40. How should we do w/o IVUS  Always we try to do reverse CART at closest point.  But sometimes failed even using bigger balloon… A R A R A R PP SP PS SS A R

41. How should we do w/o IVUS  Always we try to do reverse CART at closest point.  How bigger size balloon work??? A R A R A R A R PP SP PS SS YES!? YES? / NO YES!!! NO!!!

42. How should we do w/o IVUS  Always we try to do reverse CART at closest point.  How bigger size balloon work??? A R A R A R A R PP SP PS SS YES / NO! YES!!! NO!!! YES!?

43. How should we do w/o IVUS  Always we try to do reverse CART at closest point.  How bigger size balloon work??? A R A R A R A R PP SP PS SS YES ! YES / NO! YES ! NO !!!

45. IVUS : Retrograde Antegrade wire Intimal Plaque Subintima Retrograde wire Intimal Plaque Antegrade ballooning and Retrograde wiring Retrograde wiring and More proximal connection Subintima Antegrade ballooning or More distal connection Antegrade ballooning A R A R A R A R PUNCTURE!

46. IVUS : Retrograde Antegrade wire Intimal Plaque Subintima Retrograde wire Intimal Plaque Retrograde wiring & Antegrade ballooning or Direct puncture Retrograde wiring and More proximal connection Subintima Antegrade ballooning or More distal connection Antegrade ballooning A R A R A R A R PROXIMAL

47. IVUS : Retrograde Antegrade wire Intimal Plaque Subintima Retrograde wire Intimal Plaque Retrograde wiring & Antegrade ballooning or Direct puncture Retrograde wiring and More proximal connection Subintima Antegrade ballooning or More distal connection Antegrade ballooning A R A R A R A R PROXIMAL PROX

48. IVUS : Retrograde Antegrade wire Intimal Plaque Subintima Retrograde wire Intimal Plaque Retrograde wiring & Antegrade ballooning or Direct puncture Retrograde wiring and More proximal connection Subintima Antegrade ballooning or More distal connection Antegrade ballooning A R A R A R A R PROX PROXIMAL

49. How should we do w/o IVUS  Always we try to do reverse CART at closest point.  How bigger size balloon work??? A R A R A R A R PP SP PS SS YES ! YES / NO ! YES ! NO !!!

51. IVUS : Retrograde Antegrade wire Intimal Plaque Subintima Retrograde wire Intimal Plaque Antegrade ballooning and Retrograde wiring Retrograde wiring & More proximal connection or Original CART Subintima Antegrade ballooning or More distal connection Antegrade ballooning A R A R A R A R 1 PROXIMAL

52. IVUS : Retrograde Antegrade wire Intimal Plaque Subintima Retrograde wire Intimal Plaque Antegrade ballooning and Retrograde wiring Retrograde wiring & More proximal connection or Original CART Subintima Antegrade ballooning or More distal connection Antegrade ballooning A R A R A R A R PROXIMAL PROX PROX

53. IVUS : Retrograde Antegrade wire Intimal Plaque Subintima Retrograde wire Intimal Plaque Antegrade ballooning and Retrograde wiring Retrograde wiring & More proximal connection or Original CART Subintima Antegrade ballooning or More distal connection Antegrade ballooning A R A R A R A R PUNCTURE! PROXIMAL PROX PROX

55. How should we do w/o IVUS  After failure of reverse CART with bigger balloon, I still don’t have best solution… A R A R A R A R PP SP PS SS YES / NO! YES!!! NO!!! YES!?

56. Summary  Reverse CART should be tried at closest point of two wires with certain size of balloon.  Even bigger balloon doesn’t work, it means the situation of wires are PP or SP.  PP needs puncture at the point or advance retro GW which change situation to PS.  SP needs advance of retro GW to get PP or SS, or do CART.  Correct estimation is key to success but… not easy…

57. Summary  Reverse CART should be tried at closest point of two wires with certain size of balloon.  Even bigger balloon doesn’t work, it means the situation of wires are PP or SP.  PP needs puncture at the point or advance retro GW which change situation to PS.  SP needs advance of retro GW to get PP or SS, or do CART.  Correct estimation is key to success but… not easy…  So I strongly recommend use IVUS in tough situation!

58. China UAE Malaysia Malaysia Libya Bangladesh Thailand New Zealand Viet Nam

Satoru Sumitsuji – How to apply histologic information in retrograde approach without IVUS nor CT

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Satoru Sumitsuji – How to apply histologic information in retrograde approach without IVUS nor CT