1. The study evaluated subintimal tracking that occurred during chronic total occlusion percutaneous coronary intervention (CTO PCI) using antegrade and retrograde approaches.
2. Subintimal tracking was more common in the retrograde approach and in lesions with longer occlusion lengths.
3. No significant differences were found in 12-month target vessel revascularization rates or major adverse cardiac events between the intimal and subintimal tracking groups for either approach.
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.
This document discusses limitations of collateral channel crossing during retrograde chronic total occlusion percutaneous coronary intervention (CTO PCI). Approximately 20% of cases cannot pass the collateral channel with a wire, and 3-5% cannot follow with a microcatheter after wire crossing. Strategies to improve collateral crossing include using different microcatheters, guide support, anchoring balloons, and dilating select septal collaterals. The conclusion is that improving collateral crossing techniques and devices can enhance safety and efficiency of retrograde CTO PCI by reducing complications from collateral injuries. Five case examples are presented to demonstrate challenges and approaches.
Emmanouil S. Brilakis - Antegrade dissection re-entry step by stepEuro CTO Club
1. Antegrade dissection re-entry (ADR) is a critical technique in the hybrid algorithm for chronic total occlusion (CTO) percutaneous coronary intervention (PCI).
2. ADR provides higher technical and procedural success rates compared to antegrade wiring alone and has a safety profile similar to retrograde wiring.
3. Long-term outcomes data shows no increased risk of restenosis with ADR.
This document discusses strategies and techniques for managing chronic total occlusions (CTO). It provides details on the histopathology of CTOs and explains why recanalizing them can provide clinical benefits like relieving angina and improving left ventricular function. It describes various CTO management techniques including pre-procedure planning, guide catheter selection, and use of specialized CTO guidewires. Predictors of procedural success and failure are also reviewed.
This document summarizes the results of a study analyzing the angiographic and clinical outcomes of patients who underwent successful percutaneous coronary intervention (PCI) to treat a chronic total occlusion (CTO). The study found that the use of everolimus-eluting stents was associated with significantly lower rates of CTO vessel reocclusion compared to first-generation drug-eluting stents. Additionally, the use of the STAR technique for CTO PCI was associated with a very high rate of vessel reocclusion despite initial success. Patients treated with everolimus-eluting stents or conventional antegrade/retrograde approaches had much higher sustained vessel patency linked to improved one-year clinical outcomes.
15:35 Rinfret - Wire maneuvers in retrogade PCIEuro CTO Club
1) Retrograde PCI requires specific wire maneuvers to be mastered, including septal channel surfing, straight wire fast drilling, controlled drilling with sharp wires, and using knuckled wires.
2) These techniques allow for retrograde crossing of collateral channels, occluded grafts, and CTO lesions.
3) With practice of these simple maneuvers, retrograde PCI can be performed safely and effectively.
Trapped and lost devices – Leave it or retrieve it?Euro CTO Club
1) The document discusses complications that can occur during percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs), including equipment loss or entrapment of guidewires, microcatheters, and rotablator burrs.
2) Specific cases are presented where a guidewire became knotted and trapped during a retrograde approach, a microcatheter tip ruptured while attempting to cross a CTO, and a rotablator burr became stuck in the distal coronary artery.
3) Techniques explored to resolve equipment entrapment include wire snaring and retrieval, using a second wire or balloon to free the trapped device, and switching to an antegrade approach or surgery. Care
A 56-year-old male with a history of heart disease presented with ongoing chest pain after an unsuccessful attempt to open a chronic total occlusion of the right coronary artery via percutaneous coronary intervention 6 weeks prior. The patient underwent a second PCI procedure where the CTO was successfully opened using an antegrade approach, resolving his symptoms. At follow-ups 6 months, 12 months and 18 months later, the patient reported continued relief from symptoms and was able to return to exercising and training for triathlons without any chest pain.
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.
This document discusses limitations of collateral channel crossing during retrograde chronic total occlusion percutaneous coronary intervention (CTO PCI). Approximately 20% of cases cannot pass the collateral channel with a wire, and 3-5% cannot follow with a microcatheter after wire crossing. Strategies to improve collateral crossing include using different microcatheters, guide support, anchoring balloons, and dilating select septal collaterals. The conclusion is that improving collateral crossing techniques and devices can enhance safety and efficiency of retrograde CTO PCI by reducing complications from collateral injuries. Five case examples are presented to demonstrate challenges and approaches.
Emmanouil S. Brilakis - Antegrade dissection re-entry step by stepEuro CTO Club
1. Antegrade dissection re-entry (ADR) is a critical technique in the hybrid algorithm for chronic total occlusion (CTO) percutaneous coronary intervention (PCI).
2. ADR provides higher technical and procedural success rates compared to antegrade wiring alone and has a safety profile similar to retrograde wiring.
3. Long-term outcomes data shows no increased risk of restenosis with ADR.
This document discusses strategies and techniques for managing chronic total occlusions (CTO). It provides details on the histopathology of CTOs and explains why recanalizing them can provide clinical benefits like relieving angina and improving left ventricular function. It describes various CTO management techniques including pre-procedure planning, guide catheter selection, and use of specialized CTO guidewires. Predictors of procedural success and failure are also reviewed.
This document summarizes the results of a study analyzing the angiographic and clinical outcomes of patients who underwent successful percutaneous coronary intervention (PCI) to treat a chronic total occlusion (CTO). The study found that the use of everolimus-eluting stents was associated with significantly lower rates of CTO vessel reocclusion compared to first-generation drug-eluting stents. Additionally, the use of the STAR technique for CTO PCI was associated with a very high rate of vessel reocclusion despite initial success. Patients treated with everolimus-eluting stents or conventional antegrade/retrograde approaches had much higher sustained vessel patency linked to improved one-year clinical outcomes.
15:35 Rinfret - Wire maneuvers in retrogade PCIEuro CTO Club
1) Retrograde PCI requires specific wire maneuvers to be mastered, including septal channel surfing, straight wire fast drilling, controlled drilling with sharp wires, and using knuckled wires.
2) These techniques allow for retrograde crossing of collateral channels, occluded grafts, and CTO lesions.
3) With practice of these simple maneuvers, retrograde PCI can be performed safely and effectively.
Trapped and lost devices – Leave it or retrieve it?Euro CTO Club
1) The document discusses complications that can occur during percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs), including equipment loss or entrapment of guidewires, microcatheters, and rotablator burrs.
2) Specific cases are presented where a guidewire became knotted and trapped during a retrograde approach, a microcatheter tip ruptured while attempting to cross a CTO, and a rotablator burr became stuck in the distal coronary artery.
3) Techniques explored to resolve equipment entrapment include wire snaring and retrieval, using a second wire or balloon to free the trapped device, and switching to an antegrade approach or surgery. Care
A 56-year-old male with a history of heart disease presented with ongoing chest pain after an unsuccessful attempt to open a chronic total occlusion of the right coronary artery via percutaneous coronary intervention 6 weeks prior. The patient underwent a second PCI procedure where the CTO was successfully opened using an antegrade approach, resolving his symptoms. At follow-ups 6 months, 12 months and 18 months later, the patient reported continued relief from symptoms and was able to return to exercising and training for triathlons without any chest pain.
Karl ISAAZ - CTO withHeavy CalcificationsEuro CTO Club
This document discusses techniques for percutaneous coronary intervention (PCI) of chronic total occlusions (CTOs) with heavy calcification. It notes the difficulties posed by calcification, including inability to penetrate caps or advance wires and devices. Strategies discussed include long sheaths, large guiding catheters, stiff wires, guideliners, small balloons, microcatheters like Tornus and Turnpike, rotablator, laser, subintimal dissection with reentry, anchoring balloons, and wire escalation. Case examples demonstrate successful crossing with anchoring balloons, guideliner support, Turnpike catheter, and modified dissection and reentry. The conclusion stresses perseverance, augmented backup,
Saturday 0930 – Werner - Complication Management in PCI for Chronic Total Cor...Euro CTO Club
1) The retrograde approach for chronic total occlusion recanalization leads to increased levels of markers of myocardial injury compared to the antegrade approach, with higher levels seen following septal pathway dilation and epicardial procedures.
2) While periprocedural increases in markers like CK and troponin I are common with retrograde CTO PCI, the clinical significance is unclear as short-term outcomes are generally good.
3) Further study is needed to determine if current definitions of periprocedural myocardial infarction need revising for complex PCI procedures given the sensitivity of current biomarkers.
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.
This document discusses treatment strategies for coronary bifurcation lesions within chronic total occlusions (CTOs). It reports that true CTO bifurcations, defined as having a side branch within 5mm of the CTO, occur in approximately one-third of CTO cases. Treating bifurcation lesions within CTOs can be more technically challenging and is associated with lower success rates and higher complication risks compared to non-bifurcation CTOs. Losing important side branches during CTO treatment may negatively impact long-term clinical outcomes. The document evaluates different stenting strategies for CTO bifurcations such as provisional stenting, culotte stenting, and crush stenting and discusses guidance on complex scenarios including post-C
This document discusses strategies and techniques for managing chronic total occlusions (CTO). CTOs are coronary blockages that are completely blocked for more than 3 months. The document outlines the histopathology of CTOs and factors that predict success or failure of percutaneous coronary intervention (PCI). It also describes various guidewires, microcatheters, and crossing devices that can be used to recanalize CTOs via antegrade or retrograde approaches. Successful PCI of CTOs has been shown to improve angina, reduce the need for bypass surgery, and improve survival.
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
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.
Philip Dingli. Javier Escaned - Intracoronary imaging in CTOs When to use, ho...Euro CTO Club
This document discusses the use of intravascular ultrasound (IVUS) in percutaneous coronary interventions (PCI) for chronic total occlusions (CTOs). It provides examples of how IVUS can aid in CTO procedures, including guiding wiring, assessing vessel size for balloon sizing, and optimizing stent placement. While IVUS use was associated with longer procedures, more contrast and radiation exposure, it did not negatively impact success rates or safety outcomes. IVUS may help with complex CTO cases and provide information on vessel remodeling and stent expansion to reduce risks of restenosis.
10:50 Ochiai - 10 key points to avoid major complications during CTO PCIEuro CTO Club
1. The 10 key points provide guidance on avoiding major complications during chronic total occlusion percutaneous coronary intervention (CTO PCI).
2. The points emphasize minimizing radiation exposure, using high quality angiograms to plan strategies, monitoring activated clotting time, ensuring all devices are visible on fluoroscopy, using large guiding catheters without stiff tips, identifying the entry point into the CTO, using intravascular ultrasound, employing spring coil wires for collateral tracking, using knuckle wiring when vessel course is unclear, and guaranteeing stent delivery into the left circumflex artery during ostial left anterior descending CTO procedures to avoid complications.
3. The document illustrates each point using images from CTO PCI cases.
Friday 0905 – christiansen – feasibility of a cto pciEuro CTO Club
This document provides guidance on evaluating the feasibility of percutaneous coronary intervention (PCI) for a chronic total occlusion (CTO). Key factors to consider include: the patient's tolerance for a long procedure, contrast load, and radiation exposure; the CTO's proximal cap ambiguity, length, distal landing zone, and presence of interventional collaterals; and ensuring good quality angiography. With adequate planning and use of appropriate CTO techniques, feasibility is nearly always present for symptomatic patients. Success rates of CTO-PCI are reported to be 94% when using a planned approach.
Collateral crossing requires careful evaluation of angiograms to select the optimal collateral connection. Parameters like size, tortuosity, and insertion angle must be considered. Septal channels are initially approached with septal surfing to gently slide the wire through. If this fails, targeted crossing with tip injections may help reveal channel anatomy. Proper guidewire support and balloon anchoring can aid microcatheter advancement when issues arise. The goal is to safely cross collaterals and restore blood flow to the occluded vessel.
Georgios Sianos - RETROGRADE STEP BY STEP APPROACHEuro CTO Club
This document provides an overview of retrograde techniques for recanalizing chronic total occlusions (CTOs). It discusses the history and evolution of retrograde techniques, including septal collateral crossing and dilatation. Key steps in the retrograde approach like wire escalation, dissection and re-entry are outlined. Case examples demonstrate the retrograde procedure in detail. Consensus recommendations emphasize the importance of operator experience before performing retrograde CTO PCI independently. Required lab set-up and equipment are also reviewed.
Antegrade approach – how to start? Views of a minimalist and a maximalist poi...Euro CTO Club
This document discusses the minimalist versus maximalist approaches to chronic total occlusion (CTO) percutaneous coronary intervention (PCI).
The minimalist view is to treat the patient in one attempt using the most experienced operator for their lesion complexity. The maximalist view is to use all available tools and strategies to fully revascularize the patient.
The document outlines considerations for patient selection, procedural strategies like bilateral injection and maximum guide support, and tools like intravascular ultrasound (IVUS) and re-entry devices. It emphasizes that CTO PCI should always be planned and performed with a maximalist mindset to optimize outcomes.
This document provides several tips and tricks for navigating tortuous coronary arteries during cardiac catheterization procedures:
1) Shorter and more flexible stents and balloons can be delivered through more tortuous segments. An "anchor" technique using a buddy balloon can also aid delivery.
2) Stiffer wires can cause spasm, so microcatheters, buddy balloons, and telescopic guide systems may help. The Hi-Torque Wiggle wire can deflect to pass tortuous segments.
3) While rapid-exchange devices are faster, over-the-wire devices may track and deliver better in tortuosity. Laser or rotablater should be avoided due to risk of complications
Gerald Werner - AntegradeApproach Step by StepEuro CTO Club
This document discusses the antegrade approach for treating chronic total occlusions (CTOs). The goals are to restore the original artery anatomy with minimal damage or time/resources. The antegrade approach involves analyzing the lesion and patient, using a step-by-step process starting with softer wires and progressing if needed. Parallel wiring is an early bailout option. Guided reentry may be used if retrograde proves difficult. The strategy aims to select the approach most likely to succeed for each specific lesion and patient.
Friday 1758 – goicolea pathology of ctoEuro CTO Club
This document discusses the pathology of chronic total occlusions (CTOs) in coronary arteries. It summarizes findings from a study of 95 CTO lesions examining differences between CTOs with prior bypass grafting, long-duration CTOs without grafting, and short-duration CTOs without grafting. Key findings include that CTOs with prior grafting had more calcification and organized thrombus compared to long-duration CTOs, and short-duration CTOs had more necrotic cores. About half of proximal CTO lumens were abrupt while most distal lumens were tapered. CTOs with prior grafting and long-duration CTOs showed more negative arterial remodeling compared to short
This document discusses strategies for chronic total occlusion percutaneous coronary intervention (CTO PCI), specifically the criteria for choosing an antegrade versus retrograde approach. The key points are:
1) An antegrade wire should generally be placed first before attempting a retrograde approach to help connect the wires and reduce retrograde dwelling time.
2) Exceptions include when targeting ostial lesions or bifurcations where antegrade wiring risks side branch loss.
3) The decision of when to stop antegrade wiring and switch to retrograde depends on the specific lesion characteristics and may require balancing wire passage risks with procedural time.
08:30 Asakura - How to Succeed in Reverse - CART TechniqueEuro CTO Club
This document describes techniques for recanalization of chronic total occlusions (CTOs) including reverse CART (retrograde approach through collateral channels). It discusses 1) previous standardized retrograde techniques using retrograde wiring and kissing wire techniques, 2) limitations of these techniques, 3) the concept of contemporary reverse CART using antegrade ballooning instead of retrograde wiring, and 4) a recent standardized technique using IVUS guidance for improved outcomes. The success rate for recanalization using these reverse CART techniques was reported as 96%.
Friday 1200 – tsuchikane - retrograde std and cart approachEuro CTO Club
This document discusses strategies for crossing chronic total occlusions (CTOs). It begins by reviewing new guidewires for crossing collateral channels retrogradely, such as the SUOH03 guidewire. Contemporary techniques for retrograde CTO crossing like reverse controlled antegrade and retrograde subintimal tracking (CART) are then discussed. Limitations of reverse CART include short CTOs, long ambiguous CTOs, and impossible cases where antegrade preparation is difficult. The document concludes by emphasizing the need for non-tapered guidewires or knuckle wires in challenging cases, and that traditional CART should not be forgotten. Specific devices that aid antegrade penetration discussed are the SUOH03 and Caravel
Karl ISAAZ - CTO withHeavy CalcificationsEuro CTO Club
This document discusses techniques for percutaneous coronary intervention (PCI) of chronic total occlusions (CTOs) with heavy calcification. It notes the difficulties posed by calcification, including inability to penetrate caps or advance wires and devices. Strategies discussed include long sheaths, large guiding catheters, stiff wires, guideliners, small balloons, microcatheters like Tornus and Turnpike, rotablator, laser, subintimal dissection with reentry, anchoring balloons, and wire escalation. Case examples demonstrate successful crossing with anchoring balloons, guideliner support, Turnpike catheter, and modified dissection and reentry. The conclusion stresses perseverance, augmented backup,
Saturday 0930 – Werner - Complication Management in PCI for Chronic Total Cor...Euro CTO Club
1) The retrograde approach for chronic total occlusion recanalization leads to increased levels of markers of myocardial injury compared to the antegrade approach, with higher levels seen following septal pathway dilation and epicardial procedures.
2) While periprocedural increases in markers like CK and troponin I are common with retrograde CTO PCI, the clinical significance is unclear as short-term outcomes are generally good.
3) Further study is needed to determine if current definitions of periprocedural myocardial infarction need revising for complex PCI procedures given the sensitivity of current biomarkers.
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.
This document discusses treatment strategies for coronary bifurcation lesions within chronic total occlusions (CTOs). It reports that true CTO bifurcations, defined as having a side branch within 5mm of the CTO, occur in approximately one-third of CTO cases. Treating bifurcation lesions within CTOs can be more technically challenging and is associated with lower success rates and higher complication risks compared to non-bifurcation CTOs. Losing important side branches during CTO treatment may negatively impact long-term clinical outcomes. The document evaluates different stenting strategies for CTO bifurcations such as provisional stenting, culotte stenting, and crush stenting and discusses guidance on complex scenarios including post-C
This document discusses strategies and techniques for managing chronic total occlusions (CTO). CTOs are coronary blockages that are completely blocked for more than 3 months. The document outlines the histopathology of CTOs and factors that predict success or failure of percutaneous coronary intervention (PCI). It also describes various guidewires, microcatheters, and crossing devices that can be used to recanalize CTOs via antegrade or retrograde approaches. Successful PCI of CTOs has been shown to improve angina, reduce the need for bypass surgery, and improve survival.
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
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.
Philip Dingli. Javier Escaned - Intracoronary imaging in CTOs When to use, ho...Euro CTO Club
This document discusses the use of intravascular ultrasound (IVUS) in percutaneous coronary interventions (PCI) for chronic total occlusions (CTOs). It provides examples of how IVUS can aid in CTO procedures, including guiding wiring, assessing vessel size for balloon sizing, and optimizing stent placement. While IVUS use was associated with longer procedures, more contrast and radiation exposure, it did not negatively impact success rates or safety outcomes. IVUS may help with complex CTO cases and provide information on vessel remodeling and stent expansion to reduce risks of restenosis.
10:50 Ochiai - 10 key points to avoid major complications during CTO PCIEuro CTO Club
1. The 10 key points provide guidance on avoiding major complications during chronic total occlusion percutaneous coronary intervention (CTO PCI).
2. The points emphasize minimizing radiation exposure, using high quality angiograms to plan strategies, monitoring activated clotting time, ensuring all devices are visible on fluoroscopy, using large guiding catheters without stiff tips, identifying the entry point into the CTO, using intravascular ultrasound, employing spring coil wires for collateral tracking, using knuckle wiring when vessel course is unclear, and guaranteeing stent delivery into the left circumflex artery during ostial left anterior descending CTO procedures to avoid complications.
3. The document illustrates each point using images from CTO PCI cases.
Friday 0905 – christiansen – feasibility of a cto pciEuro CTO Club
This document provides guidance on evaluating the feasibility of percutaneous coronary intervention (PCI) for a chronic total occlusion (CTO). Key factors to consider include: the patient's tolerance for a long procedure, contrast load, and radiation exposure; the CTO's proximal cap ambiguity, length, distal landing zone, and presence of interventional collaterals; and ensuring good quality angiography. With adequate planning and use of appropriate CTO techniques, feasibility is nearly always present for symptomatic patients. Success rates of CTO-PCI are reported to be 94% when using a planned approach.
Collateral crossing requires careful evaluation of angiograms to select the optimal collateral connection. Parameters like size, tortuosity, and insertion angle must be considered. Septal channels are initially approached with septal surfing to gently slide the wire through. If this fails, targeted crossing with tip injections may help reveal channel anatomy. Proper guidewire support and balloon anchoring can aid microcatheter advancement when issues arise. The goal is to safely cross collaterals and restore blood flow to the occluded vessel.
Georgios Sianos - RETROGRADE STEP BY STEP APPROACHEuro CTO Club
This document provides an overview of retrograde techniques for recanalizing chronic total occlusions (CTOs). It discusses the history and evolution of retrograde techniques, including septal collateral crossing and dilatation. Key steps in the retrograde approach like wire escalation, dissection and re-entry are outlined. Case examples demonstrate the retrograde procedure in detail. Consensus recommendations emphasize the importance of operator experience before performing retrograde CTO PCI independently. Required lab set-up and equipment are also reviewed.
Antegrade approach – how to start? Views of a minimalist and a maximalist poi...Euro CTO Club
This document discusses the minimalist versus maximalist approaches to chronic total occlusion (CTO) percutaneous coronary intervention (PCI).
The minimalist view is to treat the patient in one attempt using the most experienced operator for their lesion complexity. The maximalist view is to use all available tools and strategies to fully revascularize the patient.
The document outlines considerations for patient selection, procedural strategies like bilateral injection and maximum guide support, and tools like intravascular ultrasound (IVUS) and re-entry devices. It emphasizes that CTO PCI should always be planned and performed with a maximalist mindset to optimize outcomes.
This document provides several tips and tricks for navigating tortuous coronary arteries during cardiac catheterization procedures:
1) Shorter and more flexible stents and balloons can be delivered through more tortuous segments. An "anchor" technique using a buddy balloon can also aid delivery.
2) Stiffer wires can cause spasm, so microcatheters, buddy balloons, and telescopic guide systems may help. The Hi-Torque Wiggle wire can deflect to pass tortuous segments.
3) While rapid-exchange devices are faster, over-the-wire devices may track and deliver better in tortuosity. Laser or rotablater should be avoided due to risk of complications
Gerald Werner - AntegradeApproach Step by StepEuro CTO Club
This document discusses the antegrade approach for treating chronic total occlusions (CTOs). The goals are to restore the original artery anatomy with minimal damage or time/resources. The antegrade approach involves analyzing the lesion and patient, using a step-by-step process starting with softer wires and progressing if needed. Parallel wiring is an early bailout option. Guided reentry may be used if retrograde proves difficult. The strategy aims to select the approach most likely to succeed for each specific lesion and patient.
Friday 1758 – goicolea pathology of ctoEuro CTO Club
This document discusses the pathology of chronic total occlusions (CTOs) in coronary arteries. It summarizes findings from a study of 95 CTO lesions examining differences between CTOs with prior bypass grafting, long-duration CTOs without grafting, and short-duration CTOs without grafting. Key findings include that CTOs with prior grafting had more calcification and organized thrombus compared to long-duration CTOs, and short-duration CTOs had more necrotic cores. About half of proximal CTO lumens were abrupt while most distal lumens were tapered. CTOs with prior grafting and long-duration CTOs showed more negative arterial remodeling compared to short
This document discusses strategies for chronic total occlusion percutaneous coronary intervention (CTO PCI), specifically the criteria for choosing an antegrade versus retrograde approach. The key points are:
1) An antegrade wire should generally be placed first before attempting a retrograde approach to help connect the wires and reduce retrograde dwelling time.
2) Exceptions include when targeting ostial lesions or bifurcations where antegrade wiring risks side branch loss.
3) The decision of when to stop antegrade wiring and switch to retrograde depends on the specific lesion characteristics and may require balancing wire passage risks with procedural time.
08:30 Asakura - How to Succeed in Reverse - CART TechniqueEuro CTO Club
This document describes techniques for recanalization of chronic total occlusions (CTOs) including reverse CART (retrograde approach through collateral channels). It discusses 1) previous standardized retrograde techniques using retrograde wiring and kissing wire techniques, 2) limitations of these techniques, 3) the concept of contemporary reverse CART using antegrade ballooning instead of retrograde wiring, and 4) a recent standardized technique using IVUS guidance for improved outcomes. The success rate for recanalization using these reverse CART techniques was reported as 96%.
Friday 1200 – tsuchikane - retrograde std and cart approachEuro CTO Club
This document discusses strategies for crossing chronic total occlusions (CTOs). It begins by reviewing new guidewires for crossing collateral channels retrogradely, such as the SUOH03 guidewire. Contemporary techniques for retrograde CTO crossing like reverse controlled antegrade and retrograde subintimal tracking (CART) are then discussed. Limitations of reverse CART include short CTOs, long ambiguous CTOs, and impossible cases where antegrade preparation is difficult. The document concludes by emphasizing the need for non-tapered guidewires or knuckle wires in challenging cases, and that traditional CART should not be forgotten. Specific devices that aid antegrade penetration discussed are the SUOH03 and Caravel
Saturday 1400 - Brilakis - Antegrade dissectionre-entry during CTO PCIEuro CTO Club
1) The document describes a presentation on using intravascular imaging such as IVUS and OCT to guide antegrade dissection and re-entry (ADR) techniques during chronic total occlusion (CTO) percutaneous coronary intervention (PCI).
2) Several case examples are shown where imaging helped select the re-entry zone, identify failed re-entry, and confirm successful re-entry. Imaging also helped decide whether or not to deploy stents and assess the final results by distinguishing dissection from disease.
3) The presentation concludes that intravascular imaging plays an important role in facilitating re-entry, assessing the need for stenting, and evaluating the results during CTO PCI procedures that use ADR techniques.
08:45 CASE 7 - Galassi - 01. A Likely “Simple” Reverse CARTEuro CTO Club
This document summarizes a complex percutaneous coronary intervention to treat a chronic total occlusion of the right coronary artery using a reverse controlled antegrade and retrograde subintimal tracking (CART) technique. After several failed attempts using various guidewires and microcatheters, the interventionist was eventually able to establish subintimal access and wire crossing in both the antegrade and retrograde directions. An externalization maneuver was then performed and four drug-eluting stents were implanted, successfully revascularizing the target lesion. The interventionist notes that reverse CART can be an effective retrograde strategy and that antegrade intravascular ultrasound or alternative techniques like Crossboss may aid in complex cases.
Dimitri Karmpaliotis - CTO PCI in Post-CABG PatientsEuro CTO Club
1) Over 100,000 CABG operations are performed annually in the US, with 10,000 re-do CABG procedures each year. Hundreds of thousands of post-CABG patients have occluded/degenerated grafts causing symptoms that are often under-treated.
2) CTO PCI in post-CABG patients is more technically challenging due to diffuse disease, calcified vessels, distortion of anatomy from vessel tenting, and progression of native vessel disease.
3) Technical success rates for CTO PCI in post-CABG patients have improved in recent years to over 80% due to improved techniques like retrograde recanalization, but it remains a difficult subset of patients with
Imre UNGI - Long-term out come of DES in CTOsEuro CTO Club
1) The document discusses long-term outcomes of drug-eluting stents (DES) compared to bare-metal stents (BMS) for treating chronic total occlusions (CTO).
2) Studies show that second-generation DES have better long-term outcomes than first-generation DES or BMS for CTO lesions.
3) Optical coherence tomography (OCT) findings indicate higher rates of uncovered and malapposed stent struts with DES in CTO lesions, suggesting increased risk of stent thrombosis, and importance of regular follow-up.
Nicolaus Reifart - How to minimize radiationEuro CTO Club
This document provides 10 steps to minimize radiation exposure during percutaneous coronary interventions (PCI). It emphasizes applying the ALARA (as low as reasonably achievable) principle. The most important step is ensuring the procedure is truly necessary. Other key steps include using protective shielding close to the patient's body, positioning the detector closer to minimize scatter radiation, avoiding oblique angles when possible, reducing frame rates, using fluoroscopy instead of cine when able, and stepping back from the patient during imaging. Adopting these good radiation safety habits can reduce radiation dose by 30-80% depending on the technique. The document stresses tailoring dye usage based on kidney function and using superselective injections when possible to minimize dye consumption as well
08:25 Di Mario - Recent Pubblications and ResearchEuro CTO Club
- Recent publications on CTOs from 2013-2014 focused on pathology, physiology, epidemiology, outcomes, imaging, technical approaches, and stents.
- Studies showed differences in plaque characteristics between long and short duration CTOs and impact of revascularizing CTOs on donor arteries.
- Registry data from Sweden found a 10.6% prevalence of CTOs and decreasing rates over time.
- Successful CTO PCI was associated with improved survival, less cardiac death, and reduced need for CABG compared to failed procedures.
- Imaging like IVUS and CT angiography improved technical success rates for CTO PCI.
Alfredo R. Galassi - The Euro CTO Club: The RegistryEuro CTO Club
The document summarizes findings from the Euro CTO Club registry regarding chronic total occlusion (CTO) percutaneous coronary intervention (PCI) from 2008-2015. Key points include:
- The number of CTO PCI procedures increased annually in the registry from about 1000 to 2500.
- Overall success rates have remained stable around 85-90% for the past 5 years.
- Retrograde procedures increased significantly after 2011, accounting for up to 35% of cases.
- Complication rates remained below 1.5-2%.
- Higher scores on the J-CTO scale predict need for hybrid/retrograde approaches and dissection re-entry techniques to successfully treat more complex C
CTO PCI in secondary revascularisation after CABG can be challenging due to worse lesion characteristics like heavy calcium. Bypass grafts, whether patent or occluded, can be used as conduits for retrograde guidewires using techniques like CART. Achieving complete revascularization after PCI late post-CABG is associated with better long-term outcomes and mortality compared to incomplete revascularization of one or more regions.
This document discusses how to perform and interpret coronary angiography for chronic total occlusion (CTO) recanalization. It emphasizes getting specific anatomic information from the angiogram such as vessel course, lesion length and characteristics, proximal and distal ambiguities, collateral circulation, and distal runoff to guide CTO PCI strategy and determine if a case is suitable. Key factors include obtaining high quality injection with optimal views of the occluded segment and ensuring good support is possible from donor vessels or collaterals. The angiogram should be studied in detail to answer questions about the CTO anatomy prior to attempting recanalization.
Andrea Gagnor - Femoral is (still) betterEuro CTO Club
This document discusses the use of radial versus femoral access for complex CTO PCI procedures. It notes that while radial access is associated with less radiation exposure and procedure time, it has technical limitations for complex CTO cases where larger devices are needed. The conclusion is that radial access can be used for simpler antegrade or retrograde CTO cases not requiring multiple devices, but femoral is generally better suited for more complex multi-device cases due to the ability to accommodate larger profiles. Safety must also be considered, as radial procedures are associated with risks like spasm that can prolong time.
15:20 Tsuchikane - Retrograde complicationEuro CTO Club
This document discusses complications that can occur during retrograde percutaneous coronary intervention (PCI) to treat chronic total occlusions (CTOs). It notes that retrograde approach relevant complications include channel perforation by wiring in epicardial arteries, channel rupture due to catheters in septal or epicardial arteries, and donor artery issues like thrombosis or dissection. Specific cases are presented where these complications occurred along with how they were addressed, such as prolonged balloon inflation, coil embolization, or neutralization of heparin. Prevention strategies are also discussed such as maintaining adequate activated clotting time and flushing guide catheters. The document aims to help operators dealing with CTO PCI to recognize and manage potential complications
TomaszJ. Guzik - Is chronic total occlusion a step in atherosclerosis natural...Euro CTO Club
Chronic total occlusion may be more than just the natural progression of atherosclerosis. It may be a consequence of chronic plaque instability and inflammation over time. The pathogenesis of CTOs involves neovascularization within plaques, changes in plaque composition like necrosis, thrombosis, and calcification, and an increased inflammation score compared to other plaques. Understanding the biomarkers and pathogenesis of CTOs could help with prevention and treatment strategies for coronary artery disease.
Drs Katoh, Suzuki, Tamai - 1995/96 in Frankfurt learning from each other push...Euro CTO Club
This document discusses the history and activities of the EuroCTO Club, a group dedicated to increasing success rates for chronic total occlusion percutaneous coronary intervention (CTO PCI). Key points:
- The Club was founded in 2006 in Frankfurt by interventional cardiologists wanting to exchange experience and develop common CTO PCI strategies.
- Early meetings involved analyzing cases to learn from each other. Success rates increased from their first attempt, where 9 of 10 CTO cases were successful.
- Over time the Club grew substantially, publishing papers and holding courses. Their online registry monitored over 4,300 cases to ensure data credibility.
- Monitoring of a sample of registry entries found high consistency, confirming the registry is a
PCI for chronic total occlusions (CTO) has a low success rate for most operators, around 70%, while expert CTO operators have a success rate of 85-95%. Expert clubs have played an important role in standardizing techniques and consolidating knowledge, helping to increase the overall CTO success rate to around 80-90% of patients. The higher success rates of experts influences more widespread adoption of treating CTO patients.
Meruzhan Saghatelyan - Retrograde Cases with serious complications: Benign co...Euro CTO Club
Case 1 resulted in perforation of the proximal RCA and rupture of the atrial collateral channel during a retrograde CTO recanalization procedure due to manipulation of stiff wires and the Corsair microcatheter in a long and angulated lesion. The patient experienced a benign clinical course.
Case 2 resulted in extravasation during retrograde CTO recanalization of the distal RCA due to perforation from stiff wire manipulation to penetrate the distal cap. The patient experienced hypotension and impaired right ventricle function but recovered after pericardial drainage.
Case 3 involved a high-risk patient with diffuse coronary artery disease. During attempted antegrade recanalization of the RCA and distal LM
Omer Goktekin - TransradialApproach is BetterEuro CTO Club
The document discusses the advantages of the transradial approach for percutaneous coronary interventions including CTO PCI, with benefits such as reduced vascular complications, patient comfort, and early ambulation compared to the transfemoral approach. While the transradial approach is technically more challenging, studies have shown comparable success rates for CTO PCI between the two approaches. The document also reviews data demonstrating the feasibility and safety of using large bore guides and bilateral transradial access for complex CTO PCI cases.
Intersphincteric resection is a technique that allows for sphincter-preserving surgery for rectal cancers located 1-2 cm from the anal verge. The procedure involves partial resection of the internal anal sphincter while completely preserving the external anal sphincter. A study of 90 patients who underwent this surgery found that 82% had 5-year overall survival and 75% had 5-year disease-free survival. While 41% had perfect post-operative continence, 76% reported overall subjective satisfaction with functional results. Preoperative radiotherapy was associated with worse functional outcomes.
Antegrade approach to coronary chronic total occlusionRamachandra Barik
The document describes a study examining the use of polymer-jacketed, tapered-tip, low-force guidewires with composite-core and dual-coil design (Fielder XT-R and XT-A wires) for the antegrade approach to chronic total occlusion percutaneous coronary interventions. 164 consecutive CTO lesions treated at a single institution using the Fielder wires as the starting wire were analyzed. Technical success rates using the Fielder wires antegrade were 79%, 60%, and 17% for lesions with J-CTO scores of 0-1, 2-3, and 4-5 respectively. Successful antegrade cases had median wiring times of 6.5 to 12 minutes depending on J-
- A study analyzed data from the DIG trial to examine the effect of digoxin on 30-day hospital admissions in older adults with heart failure.
- The study found that digoxin reduced the absolute risk of all-cause hospital admission within 30 days by 2.7% and the relative risk by 34% compared to placebo. Digoxin also reduced the risk of cardiovascular hospital admissions at 30 days by 47%.
- The beneficial effect of digoxin on reducing 30-day hospital admissions persisted out to 60 and 90 days with no signs of harm, suggesting digoxin provides early benefits without increasing later risks.
This study evaluated whether administering nitroglycerin through the sheath at the end of a transradial catheterization procedure reduces radial artery occlusion. Over 1700 patients were randomly assigned to receive either 500 μg of nitroglycerin or a placebo saline solution intra-sheath after transradial catheterization. Radial artery patency was assessed by ultrasound the next day. The incidence of radial artery occlusion was lower in the nitroglycerin group compared to placebo at 8.3% vs 11.7%. Administration of nitroglycerin through the sheath may reduce radial artery occlusion by its vasodilatory effects.
Small AVMs that are deep or in eloquent areas are often treated with radiosurgery instead of surgery. Radiosurgery uses a single high dose of radiation and has an obliteration rate of 70-80% at 2 years. Frame-based radiosurgery requires invasive head fixation for imaging and treatment, while frameless radiosurgery with the Cyberknife does not require an invasive frame. Preliminary studies show frameless radiosurgery has obliteration rates similar to frame-based radiosurgery but is better tolerated as an outpatient procedure without head frame fixation.
This document discusses the management of diffuse gliomas and outlines the workflow for stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT). It covers topics such as target delineation, motion management, dose prescription, plan evaluation, quality assurance, and the importance of education. Strict immobilization and minimizing errors are emphasized for SRS and SBRT. Various motion management systems and techniques for different tumor sites are presented. Metrics for evaluating plan quality like coverage, conformity, homogeneity and dose to organs-at-risk are defined. The document stresses the need to balance optimal target coverage while restricting dose to nearby organs.
- Extended waiting time of more than 8 weeks between neoadjuvant chemoradiation and surgery for locally advanced rectal cancer resulted in higher rates of R0 resection and pathologic complete response compared to surgery within 8 weeks in a retrospective study. However, timing of full dose adjuvant chemotherapy may be delayed with longer waiting periods.
- Local excision after neoadjuvant chemoradiation or non-operative "wait and see" approaches may enable organ preservation in some patients who achieve a clinical complete response. However, accurate assessment of response can be challenging and long-term oncologic outcomes require further study.
P. Genereux, the tryton stent_dedicated bifurcation stent in coronary bifurca...trytonmedical
This document provides disclosure of financial interests and background on the TRYTON dedicated bifurcation stent presented by Dr. Philippe Généreux at TCT 2016. It notes that Dr. Généreux receives consulting fees and is a major shareholder in TRYTON Medical. The document then summarizes the design and deployment of the TRYTON stent, results from the pivotal RCT showing non-inferiority for the primary endpoint but superiority for the secondary angiographic endpoint of side branch diameter stenosis. It concludes by outlining the rationale and design of the TRYTON confirmatory study to further evaluate safety in large side branches.
1) The document describes equine tenoscopy techniques and findings from studies on non-septic tenosynovitis of the digital flexor tendon sheath.
2) Ultrasound was found to be minimally invasive but not as accurate as tenoscopy for diagnosing intra-thecal pathology. Tenoscopy identified longitudinal tears of the superficial and deep digital flexor tendons in many cases.
3) Outcomes from tenoscopy treatment of longitudinal tendon tears and torn manica flexoria were mixed, with around 30-40% of tendon tear cases and over 80% of manica flexoria tear cases returning to previous work levels. However, controlled studies comparing tenoscopy to rest alone are still
1) The document provides information on the efficacy of different treatment modalities for esophageal strictures including dilation, stenting and intralesional steroid injections.
2) Data from studies show that fully covered self-expanding metal stents (SEMS) achieve clinical success in 30-66% of patients with refractory strictures, but have migration rates of 14-37%.
3) Biodegradable stents have a lower clinical success rate of 30-33% and require frequent reinterventions, but avoid issues of migration associated with metal stents.
This document describes the case of a 52-year-old male who presented with vomiting and was found to have a pituitary adenoma. An MRI showed a 2.3x1.6 cm dumbbell shaped lesion in the sella turcica extending suprasellarly and compressing the optic chiasm. The patient underwent endoscopic transphenoidal resection, with near total excision. Post-op MRI showed residual tissue in the right and left sides of the sella. The patient was planned for stereotactic radiotherapy with 25Gy in 5 fractions to treat the residual tumor. Target and organ at risk volumes were delineated on planning MRI and CT scans. Treatment planning was performed to optimize dose distribution and minimize
15th Experts Live CTO - Carlo Di Mario: ConclusionsEuro CTO Club
PLENARY SESSION
Wrap up of live cases, awards to the winners of the best abstracts and case competitions and take home messages
Auditorium Zubin Mehta - Saturday 16:00 - 17:00
Speakers:
Daniela Benedetto (Rome),
Francesco Burzotta (Rome),
Carlo Di Mario (Florence),
Roberto Garbo (Turin),
Rocco Stio (Rome)
Challengers:
Stelios Pyxaras (Furth - D),
Sudhir Rathore (London - UK)
Discussants:
Shunsuke Matsuno (Tokyo - J),
Alexander Nap (Amsterdam - NL),
Masahisa Yamane (Tokyo - J)
___________________________________________
15th Experts Live CTO,
EUROCTO Club meeting in partnership with the GISE CTO meeting.
September 8th - 9th, 2023
Florence, Italy
Francesco Burzotta: Wrap up Gemelli CasesEuro CTO Club
PLENARY SESSION
Wrap up of live cases, awards to the winners of the best abstracts and case competitions and take home messages
Auditorium Zubin Mehta - Saturday 16:00 - 17:00
Speakers:
Daniela Benedetto (Rome),
Francesco Burzotta (Rome),
Carlo Di Mario (Florence),
Roberto Garbo (Turin),
Rocco Stio (Rome)
Challengers:
Stelios Pyxaras (Furth - D),
Sudhir Rathore (London - UK)
Discussants:
Shunsuke Matsuno (Tokyo - J),
Alexander Nap (Amsterdam - NL),
Masahisa Yamane (Tokyo - J)
___________________________________________
15th Experts Live CTO,
EUROCTO Club meeting in partnership with the GISE CTO meeting.
September 8th - 9th, 2023
Florence, Italy
Jonathan Hill: Role of mechanica support in CTO recanalizationEuro CTO Club
10:42
Role of mechanica support in CTO recanalization
Jonathan Hill (London - UK)
___________________________________________
PARALLEL SESSION
Challenges And Opportunities In Cto Recanalization
Auditorium Zubin Mehta - Saturday 10:00 - 11:10
Chairperson:
Jonathan Hill (London - UK)
Discussants:
Lesnek Bryniarski (Krakow - PL),
Ugo Fabrizio (Vercelli),
Paul Knaapen (Amsterdam - NL),
Eugenio La Scala (Ollioiouls - F)
___________________________________________
15th Experts Live CTO,
EUROCTO Club meeting in partnership with the GISE CTO meeting.
September 8th - 9th, 2023
Florence, Italy
Gregor Leibundgut: Role of DEB in CTO-PCIEuro CTO Club
10:35 Role of DEB in CTO-PCI
Gregor Leibundgut (Basel - CH)
___________________________________________
PARALLEL SESSION
Challenges And Opportunities In Cto Recanalization
Auditorium Zubin Mehta - Saturday 10:00 - 11:10
Chairperson:
Jonathan Hill (London - UK)
Discussants:
Lesnek Bryniarski (Krakow - PL),
Ugo Fabrizio (Vercelli),
Paul Knaapen (Amsterdam - NL),
Eugenio La Scala (Ollioiouls - F)
___________________________________________
15th Experts Live CTO,
EUROCTO Club meeting in partnership with the GISE CTO meeting.
September 8th - 9th, 2023
Florence, Italy
Kambis Mashayekhi: EuroCTO Consensus on treatment of Calcified CTO lesion Eur...Euro CTO Club
AUDITORIUM ZUBIN MEHTA
08/09/2023 04:30 - 05:20
PLENARY SESSION - INTERVENTIONAL CTO & CHIP RESEARCH Best CTO Publications 2022-23 (selected by the Editors of the Cardiology Interventional journals)
Emmanouil S. Brilakis - CTO PCI Outcome associated with poor quality of the d...Euro CTO Club
16:53
CTO PCI Outcome associated with poor quality of the distal target vessel
Emmanouil Brilakis (Minneapolis - USA)
_____________________________________________
PARALLEL SESSION
Interventional CTO & Chip Research
Best CTO Publications 2022-23 (selected by the Editors of the Cardiology Interventional journals)
Auditorium Zubin Mehta - Friday 16:30 - 17:16
Chairpersons:
Davide Capodanno (Catania),
Carlo Di Mario (Florence),
Giuseppe Tarantini (Padua)
Panelist:
Roberto Diletti (Rotterdam - NL),
Giovanni Esposito (Naples),
Paul Knaapen (Amsterdam - NL),
Maksymilian Opolski (Warsaw - PL)
___________________________________________
15th Experts Live CTO,
EUROCTO Club meeting in partnership with the GISE CTO meeting.
September 8th - 9th, 2023
Florence, Italy
Mario Iannaccone - 2 EuroCTO Consensus on Guide Catheter Extensions JACC Card...Euro CTO Club
16:33
EuroCTO Consensus on Guide Catheter Extensions JACC Cardiovasc Interventions
Mario Iannaccone (Turin)
_____________________________________________
PARALLEL SESSION
Interventional CTO & Chip Research
Best CTO Publications 2022-23 (selected by the Editors of the Cardiology Interventional journals)
Auditorium Zubin Mehta - Friday 16:30 - 17:16
Chairpersons:
Davide Capodanno (Catania),
Carlo Di Mario (Florence),
Giuseppe Tarantini (Padua)
Panelist:
Roberto Diletti (Rotterdam - NL),
Giovanni Esposito (Naples),
Paul Knaapen (Amsterdam - NL),
Maksymilian Opolski (Warsaw - PL)
___________________________________________
15th Experts Live CTO,
EUROCTO Club meeting in partnership with the GISE CTO meeting.
September 8th - 9th, 2023
Florence, Italy
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
Adhd Medication Shortage Uk - trinexpharmacy.comreignlana06
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Does Over-Masturbation Contribute to Chronic Prostatitis.pptxwalterHu5
In some case, your chronic prostatitis may be related to over-masturbation. Generally, natural medicine Diuretic and Anti-inflammatory Pill can help mee get a cure.
Does Over-Masturbation Contribute to Chronic Prostatitis.pptx
Saturday 1050 – tsuchikane – try to stay intimal
1. Try to Stay Intimal
Etsuo Tsuchikane, MD, PhD
Toyohashi Heart Center
Nagoya Heart Center
Gifu Heart Center
2. Disclosure
Within the past 12 months, the presenter or their
spouse/partner have had a financial interest/arrangement or
affiliation with the organizations listed below.
Physician Name
Etsuo Tsuchikane, MD, PhD
Company/Relationship
Abbott Vascular, Japan Consultant
Boston Scientific, Japan Consultant
Asahi Intecc, Japan Consultant
3. a = IVUS catheter , b = Sub-Intimal space, c = the Intimal Plaque
Sub-Intimal TrackingIntimal Plaque Tracking
4. 26 CTO lesions successfully treated by a single operator
4 lesions by retrograde approach
Subintimal tracking in 45% (12/26)
Subintimal tracking was more common in reattempted case (42% vs. 7%), associated
with longer stent length (71 vs. 50 mm), procedural time (122 vs. 69 min), fluoroscopy
time (47 vs. 22 min), and contrast dose (300 vs. 199 mL).
No long-term data available (CCI 2012;79:43-48)
5. 48 CTO lesions successfully treated by a single operator
25 lesions by retrograde approach
Subintimal tracking in more common in retrograde approach (40 vs. 9%)
No long-term data available (JACC Intv 2009;2:846-54)
6. 1. How often in the contemporary CTO-PCI?
2. Any effect of short subintimal tracking on long-
term outcomes after DES?
7. J-PROCTOR REGISTRY
PROMUS STENT TREATMENT OF
CHRONIC TOTAL OCCLUSIONS
USING TWO DIFFERENT RECANALIZATION
TECHNIQUES IN JAPAN
(EuroIntervention 2014;10:681)
8. Study Design
Flow Chart
CTO Cases
Antegrade Retrograde
IVUS Check for GW penetration position
PROMUS Stent Implantation
12 mo. Clinical FU
Study Enrollment
Antegrade 50 : Retrograde 100
GW Cross Lesion Success
9 mo. Angiogram FU
Primary Endpoint: 12 mo. TVR
Secondary Endpoint: 12 mo. MACE
and Fu QCA parameters
15. Acute QCA Results
Intimal vs. Sub-Intimal
Intimal
(125)
Sub-Intimal
(31)
p value
Pre Procedure
RVD, mm 2.82±0.42 3.02±0.44 0.020
Occlusion Length, mm 18.5±14.8 23.9±20.5 0.14
Post Procedure( In stent)
RVD, mm 3.09±0.48 3.17±0.44 0.38
MLD, mm 2.60±0.46 2.61±0.37 0.91
Stent Length, mm 50.5±23.8 60.5±23.0 0.040
Acute Gain, mm 2.6 ±0.5 2.6 ±0.4 0.91
16. 9-month QCA Results
Intimal vs. Sub-Intimal
Intimal
(100)
Sub-Intimal
(22)
p value
In Stent
RVD, mm 3.00±0.46 2.95±0.41 0.87
MLD, mm 2.41±0.66 2.03±0.79 0.021
% DS, % 19.8±19.1 30.4±25.9 0.031
Late Loss, mm 0.21±0.52 0.57±0.93 0.016
Loss Index, % 7.8±22.6 19.7±30.3 0.038
Reocclusion 3.0% (3) 4.5% (1) 0.55
Aneurysm 1.0% (1) 9.1% (2) 0.08
Aneurysm (from QCA core lab) = an expansion of the lumen by at least 20% compared with the normal lumen dimensions in the
treatment region (analysis segment) that extends with a wide or narrow mouth beyond the apparent normal contour
17. Acute QCA Results
Retrograde: Intimal vs. Sub-Intimal
Intimal
(75)
Sub-Intimal
(24)
p value
Pre Procedure
RVD, mm 2.89±0.41 3.08±0.43 0.06
Occlusion Length, mm 21.5±15.5 28.1±21.1 0.14
Post Procedure( In stent)
RVD, mm 3.11±0.51 3.21±0.41 0.39
MLD, mm 2.60±0.48 2.63±0.41 0.74
Stent Length, mm 56.4±23.7 66.7±20.9 0.06
Acute Gain, mm 2.6±0.5 2.6±0.4 0.74
18. 9-month QCA Results
Retrograde: Intimal vs. Sub-Intimal
Intimal
77.3% (58)
Sub-Intimal
75.0% (18)
p value
In Stent
RVD, mm 3.02±0.49 3.00±0.43 0.86
MLD, mm 2.32±0.73 1.92±0.83 0.05
% DS, % 23.2±20.3 34.8±26.7 0.05
Late Loss, mm 0.29±0.63 0.71±0.98 0.037
Loss Index, % 10.8±24.9 24.6±31.4 0.06
Reocclusion 3.4% (2) 5.6% (1) 0.56
Aneurysm 1.7% (1) 11.1% (2) 0.14
Aneurysm (from QCA core lab) = an expansion of the lumen by at least 20% compared with the normal lumen dimensions in the
treatment region (analysis segment) that extends with a wide or narrow mouth beyond the apparent normal contour
19. J-PROCTOR Summary
• According to IVUS analysis, Sub-intimal tracking tended to be higher
in retrograde approach than antegrade.
• Lesion characteristics were more severe in Sub-intimal tracking group.
• No significant difference was observed in 1year TVR rate (primary
endpoint) between Intimal and Sub-intimal tracking groups, in both
antegrade and retrograde approach.
• Acute QCA analysis identified longer occlusion and stent lengths in the
Sub-intimal tracking group.
• FU QCA analysis showed a higher late loss in the Sub-intimal group,
but no difference in re-occlusion rate.
20. J-PROCTOR Conclusion
• No clinical negative impact by EES implantation
after localized Sub-intimal tracking in either
antegrade or retrograde manner at 1 year was
demonstrated in this study.
21. 1. Subintimal tracking is more predictable in the retrograde
approach than the antegrade. But not so common even if
reverse CART is commonly used (>50%).
2. Occlusion length may influence the incidence of subintimal
tracking in both approaches.
Lessons from J-PROCTOR
22. 13,7
17,6
43
12,3
9
45
0
10
20
30
40
50
J-Proctor Tsujita et al.* Muhammad et al.**
CTO length (mm) Incidence of subintimal tracking (%)
(**CCI 2012;79:43-48)
(*JACC Intv 2009;2:846-54)
(n=26)
4 retrograde(n=23)(n=57)
CTO length and Subintimal tracking
Antegrade approach
24. 1. Subintimal tracking is more predictable in the retrograde
approach than the antegrade. But not so common even if
reverse CART is commonly used (>50%).
2. Occlusion length may influence the incidence of subintimal
tracking in both approaches.
3. Restenosis does not always occur in DES with subintimal
dilatation.
Lessons from J-PROCTOR
25. TVR at 12 months
Antegrade (Intimal vs. Sub-intimal)
Retrograde (Intimal vs. Sub-intimal)
10.4%
(13) 8.0%
(4)
12.0%
(9)
12.9%
(4)
0%
(0)
16.7%
(4)
0%
10%
20%
30%
40%
50%
All Antegrade Retrograde
Intimal
Subintimal
p=0.75 p=1.00 p=0.51
26. 9-month QCA Results
Retrograde: Intimal vs. Sub-Intimal
Intimal
77.3% (58)
Sub-Intimal
75.0% (18)
p value
In Stent
RVD, mm 3.02±0.49 3.00±0.43 0.86
MLD, mm 2.32±0.73 1.92±0.83 0.05
% DS, % 23.2±20.3 34.8±26.7 0.05
Late Loss, mm 0.29±0.63 0.71±0.98 0.037
Loss Index, % 10.8±24.9 24.6±31.4 0.06
Reocclusion 3.4% (2) 5.6% (1) 0.56
Aneurysm 1.7% (1) 11.1% (2) 0.14
Aneurysm (from QCA core lab) = an expansion of the lumen by at least 20% compared with the normal lumen dimensions in the
treatment region (analysis segment) that extends with a wide or narrow mouth beyond the apparent normal contour
31. TVR Case in Retrograde Group #3
Subintimal tracking
Restenosis
9Mo Fu angiogram
32. No difference between 2 groups regarding the pattern of ISR. No
relationship betwen restenosis site and subintimal tracking portion
J-PROCTOR registry
Site and pattern of restenosis in patients
undergoing target vessel revascularization
33. 1. Subintimal tracking is more predictable in the retrograde
approach than the antegrade. But not so common even if
reverse CART is commonly used (>50%).
2. Occlusion length may influence the incidence of subintimal
tracking in both approaches.
3. Restenosis does not always occur in DES with subintimal
dilatation.
4. Short subintimal tracking and a final TIMI flow grade 3 with
well preserved distal side branches may not worsen the vessel
patency.
5. These suggestions warrants further evaluations.
Lessons from J-PROCTOR
34. J-PROCTOR 2 STUDY
PROMUS STENT TREATMENT OF
CHRONIC TOTAL OCCLUSIONS
USING TWO DIFFERENT RECANALIZATION
TECHNIQUES IN JAPAN
35. Retrospective analysis of successfully treated cases from
“Retrograde Summit Registry 2012” with procedural
recorded IVUS images and 1yr clinical follow-up
Same definition, inclusion and exclusion criteria as J-
PROCTOR
Independent IVUS evaluation
Primary endpoint was 1yr TVR and secondary was 1yr
MACE (same as J-PROCTOR)
Study Design
36. Enrolled CTO cases in Retrogarde
Summit Registry 2012
1573
GW cross lesion success
1411
EES implanted and matched
inclusion criteria of J-PROCTOR
894
Study Design
Flow Chart
Checked IVUS for
GW penetration position
387
No IVUS image
: 507
37. Study Enrollment
Antegrade 242 : Retrograde 81
Study Design
Flow Chart
Checked IVUS for
GW penetration position
387
Eligible for IVUS analysis
352
Poor IVUS image
: 35
Available for 12mo clinical FU
323
Primary Endpoint: 12 mo. TVR
Secondary Endpoint: 12 mo. MACE
38. Baseline Patient Characteristics
Antegrade
242
Retrograde
81
p value
Male 83.1% 79.0% 0.41
Age (years) 67.8 ±10.4 67.4 ±10.9 0.71
Previous MI 28.5% 48.1% 0.001
Previous CABG 4.1% 9.9% 0.053
Hypertension 75.2% 77.8% 0.6
Diabetes mellitus 34.3% 37.0% 0.66
Hyperlipidemia 65.7% 76.5% 0.07
Smoking 40.1% 56.8% 0.009
Average diseased vessel 1.8±0.7 1.9±0.8 0.66
Multi vessel disease 63.6% 60.5% 0.19
47. Procedural Results
by IVUS classification
Intimal
270
Sub-Intimal
53
p value
Number of GW 2.9±1.8 4.5±2.8 <0.0001
IVUS guided wiring 11.5% 41.5% <0.0001
Number of stent 1.8±0.8 2.2±0.8 0.002
Stent diameter, mm 2.9±0.3 2.8±0.3 0.17
Stent length, mm 49.2±22.9 62.5±27.0 <0.0001
Maximum stent pressure, atm 17.5±3.9 17.3±4.0 0.71
48. Procedural Results
by IVUS classification
Intimal
270
Sub-Intimal
53
p value
Procedure time, min 127.2 ±75.1 185.2±80.7 <0.0001
Contrast dose, ml 221.3±95.2 261.5±93.5 0.006
Fluoroscopic time, min 55.9±34.8 96.4±48.9 <0.0001
Procedure events 0.4% (1) 3.8% (2) 0.07
- GW perforation 0.4% (1) 1.9% (1) 0.3
- Channel injury 0% 1.9% (1) 0.16
- Donor artery trouble 0% 0% >0.99
In hospital MACE 0% 0% >0.99
Non Q wave MI 0% 0% >0.99
56. PCI Procedure
Retrograde: Intimal vs. Sub-Intimal
Intimal
56
Sub-Intimal
25
p value
Number of GW 4.1±1.8 5.9±2.6 0.003
IVUS guided wiring 39.3% 76.0% 0.002
Number of stent 1.7±0.7 1.8±0.8 0.03
Stent diameter, mm 2.9±0.3 2.9±0.3 0.21
Stent length, mm 59.7±24.4 74.0±24.4 0.02
Maximum stent pressure, atm 17.1±4.2 17.1±3.8 0.99
57. Retrograde Case 1: Mid RCA
Pre Post F/U
Sub-intimal
tracking zone
In-Stent
58. Retrograde Case 2: Distal RCA
Sub-intimal
tracking zone
Pre Post F/U
In-Stent
59. Retrograde Case 3: Mid LAD
Sub-intimal
tracking zone
Pre Post F/U
In-Stent
60. Retrograde Case 4: Proximal RCA
Sub-intimal
tracking zone
Pre Post F/U
In-Stent
61. Independent Predictors of
TVR
Overall Odds Ratio (95% CI) p value
Retrograde approach 3.6 (1.3 -10.5) 0.02
Retrograde
Bridge collateral 7.0 (9.5 -32.9) 0.01
62. Limitations
• Non randomized observational study
• Retrospective study
• Short clinical follow-up period (1 year)
• Low angiographic follow-up rate (36.8%)
63. J-PROCTOR 2 Summary
• Subintimal tracking was more predictable in the retrograde
approach (30.9% vs. 11.9%).
• In Japanese antegrade approach, TVR rate was quite low
(2.9%) in both intimal and subintimal tracking group.
• Although the occlusion length was similar, subintimal
tracking group required a longer stent length compared to
intimal tracking group in retrograde approach.
• TVR was more frequent for subintimal tracking group not in
antegrade but in retrograde approach.
• However TVR portion was not related to subintimal tracking
portion.
64. J-PROCTOR 2 Conclusion
Intimal tracking should be recommended in
retrograde approach to reduce stent length and
to improve follow-up outcomes.
However, subinitimal tracking does not
directly affect the late loss.
65. • STAR technique with KWT should never be applied
for major trunk. It’s allowable only for side branches.
• Subintimal tracking in contemporary wiring without
Stingray is not rare (>10%). However, long-term
outcomes must be good.
• How often do we need Stingray? Does it increase
overall success rate?
We Should Stay Intimal or Not?
In Antegrade Approach
66. Contemporary Japanese CTO-PCI
from Retrograde Summit Registry
2012 (1553) 2013 (1676) P
Successful CTO crossing by GW 89.6% 89.6% 0.9925
Number of guidewire used for CTO
approach
3.1±2.2 3.2±2.3 0.1788
Stent deployment 93.5% 100.0% <0.0001
Number of stent 1.8±1.0 1.9±0.9 0.0033
Total stent length, mm 51.8±24.9 55.4±27.9 0.0008
Use of drug-eluting stent 98.0% 98.8% 0.0907
Procedure success 88.3% 88.4% 0.9437
Procedure time, min 142.7±83.4 153.2±88.0 0.0012
Contrast dose, ml 228.7±107.2 226.2±103.4 0.5187
Fluoroscopy time, min 64.2±42.4 70.6±47.8 0.0002
Air Kerma, mGy 4715.8±3760.8 4920.3±3879.7 0.2031
67. Registry Overview
Retrograde Summit
General Registry
Japanese CTO PCI
Expert Registry
Organization Retrograde Summit Japanese Board of CTO
interventional specialist
Participants
As of Nov. 2014
56 of Japanese
Centers
31 of Japanese expert
Physicians
Criteria for the
Participants
Centers which were
approved by administrative
board
Cases by experts are
excluded.
• More than 300 cases of
experience of CTO-PCI
• More than 50 cases of CTO-
PCI per year
• Recommendation from two
or more steering committee
member
Core lab ー Adjudication of Success
71. GW Technique for
Successful CTO body Crossing
60%
26%
13%
1%
HC
57%31%
3%
9%
LC
Single wire
Parallel wire
IVUS guide
Other
P=0.007
Antegrade approach after
retrograde approach failure (296)
HC (131) LC (165) P value
Successful CTO body crossing by GW 74.8% (98) 54.6% (90) 0.0003
72. Development of CTO-PCI procedure
Miracle
Conquest
Parallel wiring
IVUS guidance
Retrograde approach
1995 2000 2005 2010
Fielder XT
Fielder XTR
GAIA
BridgePoint
MDCT
Corsair
wire, device
imaging modality
wiring technique
SION
2015
Euro CTO Club
Hybrid approach
CTO Fundamentals
CTO Club
75. Objective
To promote CTO-PCI based on the well developed
technology (devices, techniques) for more than 20
years in Asian-Pacific region.
To educate the next generation of Asian-Pacific CTO
operators for the patients living in this region.
76. Directors
Ji Yan Chen Guangdong General Hospital China
Lei Ge Zhongshan Hospital Fudan University China
Scott Harding Wellington Hospital New Zealand
Paul Hsien-Li Kao National Taiwan University Hospital Taiwan
Seung-Whan Lee Asan Medical Center Korea
Soo Teik Lim National Heart Centre Singapore Singapore
Sidney Tsz Ho Lo Liverpool Hospital Australia
Jie Qian Fu Wai Hospital China
Etsuo Tsuchikane Toyohashi Heart Center Japan
Eugene B. Wu Prince of Wales Hospital Hong Kong
78. Supervisors
Jumbo Ge Zhongshan Hospital Fudan University China
Yang-Soo Jang Severance Hospital, Yonsei University Hospital Korea
Osamu Katoh Japan
Tian Hai Koh National Heart Centre Singapore Singapore
Sum Kin Leung Keen Heart Medical Practice HongKong
Jim Stewart Auckland City Hospital New Zealand
Yeujin Yang Beijing Fuwai Hospital China
Chiung-Jen Wu Kaohsiung Chang Gung Memorial Hospital Taiwan
79. What’s AP CTO Club role and activity
in AP region?
• Development of AP CTO-PCI Algorithm
• Web Site Open
• Educational Training Program
– Workshop in each regional annual meeting for young
physician’s CTO training
• Web-cast Live Demonstration?
– To share CTO live-demonstration through web-cast for
education purpose
• Asian Pacific CTO Registry?
– Collect CTO data and publish as AP CTO data
• Other??
80. Retrograde approach
Features favoring early use of KWT
and/or dissection re-entry
• Ambiguous course in CTO
• Length >20 mm
• Tortuous CTO segment
• Heavy calcification
• Previous failed attempt
Consider stopping if >3 hours, 3.7 x eGFR ml contrast, Air Kerma > 5 Gy unless procedure well advanced
Proximal cap ambiguity IVUS guided entry
No
Poor quality distal vessel or
bifurcation at distal cap
Careful analysis of angiogram / MSCT
No
Yes
Yes
No
Interventional collaterals present
Yes
No
Yes
In-stent restenosis
Consider use of CrossBoss as
primary crossing strategy
Antegrade wire
based approach
Dissection Reentry
(crossboss-stingray)
Parallel wiring
IVUS guided wiring
If suitable
re-entry
zone
81. What’s AP CTO Club activities
in AP region
• “Umbrella” covering CTO workshops and major meetings in AP region
– Jun. 19-20 CTO Club in Nagoya
– Aug. 21-22 Guangzhou CTO Workshop in China
– Sep. 11-12 CTO Interventions Live course in Singapore
– Oct. 23-24 CTOCC in Shanghai
– Oct. 29-31 CCT in Kobe
– Nov. 18-20 ANZCCT in Brisbane
– Jan. 8-9 TTT in Taipei
– Mar. 17-20 CIT in Beijing
– Apr. 26 CTO Live@TCT AP in Seoul
– Jun. 9-10 ANZCTO Club in Perth
– Jun. 17-18 CTO Club in Nagoya
2015
2016
82. What’s AP CTO Club activities
in AP region
• “Umbrella” covering CTO workshops and major meetings in AP region
– Jun. 19-20 CTO Club in Nagoya
– Aug. 21-22 Guangzhou CTO Workshop in China
– Sep. 11-12 CTO Interventions Live course in Singapore
– Oct. 23-24 CTOCC in Shanghai
– Oct. 29-31 CCT in Kobe
– Nov. 18-20 ANZCCT in Brisbane
– Jan. 8-9 TTT in Taipei
– Mar. 17-20 CIT in Beijing
– Apr. 26 CTO Live@TCT AP in Seoul
– Jun. 9-10 ANZCTO Club in Perth
– Jun. 17-18 CTO Club in Nagoya
2015
2016
83. • STAR technique with KWT should never be applied
for major trunk.
• Subintimal tracking in contemporary wiring without
Stingray is not rare (>10%). However, long-term
outcomes must be good.
• The use of Stingray must be limited just because we
do not need it generally.
We Should Stay Intimal or Not?
In Antegrade Approach
84. • Reverse CART does not always cause subintimal
tracking.
• Retrograde approach requires subintimal tracking
more frequently than antegrade based on lesion
characteristics, which we can’t control techniqually.
• Two J-Proctor studies may suggest the subintimal
tracking does not always affect the late loss.
We Should Stay Intimal or Not?
In Retrograde Approach
When necessary,
we may go subintimal!
85. 17th CTO Club
June 17 fri.-18 sat., 2016, Nagoya, Japan
www.cct.gr.jp/ctoclub