Successful Retrograde Approach PCI For The Ostium of LCX Chronic Total Occlusion (CTO) via an LAD intra-diagonal collateral channel.pptx

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1) This case describes a successful retrograde percutaneous coronary intervention (PCI) for chronic total occlusion of the left circumflex artery (LCX) via an intra-left anterior descending (LAD) collateral channel. 2) An 8 French sheath and guide catheter were used from the femoral artery to facilitate the retrograde approach via the LAD collateral. 3) Dual antegrade and retrograde wire techniques including the knuckle wire technique were used to successfully cross the CTO lesion. Intravascular ultrasound (IVUS) guided the final stent placement.

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Successful Retrograde Approach PCI For The Ostium of LCX
Chronic Total Occlusion (CTO) via an LAD intra-diagonal
collateral channel
Dept. of Cardiology, Tokyo General Hospital, Japan
Yukihiro Yamaguchi, Reiko Tsukahara,
Toshiya Muramatsu, Masatsugu Nakano,
Hideyuki Takimura, Mami Kawano,
Emi Tajima, Tsuzuki Ippei,
Rintaro Taniguchi, Kurozumi Atsumasa
第59回 CVIT 関東甲信越地方会 2022

the Japanese Association of
Cardiovascular Intervention and Therapeutics
COI Disclosure
Yukihiro Yamaguchi
The authors have no financial conflicts of interest
to disclose concerning the presentation.

RAO 30° CAU 20°
’21/9 PCI for LCX CTO
 Diagnosis: SMI
 Prior intervention:
’21/4 AP (seg.1-3 EES)
 Coronary risk factor: HT, HL, OCI
 eGFR: 70 (mL/min/1.73m2)
 Syntax score: 18
 J-CTO score: 3, J-Channel score: 5
 LVEF 72.5％ (UCG)
Dept. of Cardiology, Tokyo General Hospital, Japan LAO 25° CAU 35°

RAO 40°CAU 20°
Dept. of Cardiology, Tokyo General Hospital, Japan
LAO 25°CAU 35°

Retro channel - apex channel via diagonal branch
Apex via diagonal branch
J-channel
score
LAO30°CRA20°
Dept. of Cardiology, Tokyo General Hospital, Japan
5 (Small, Reverse bend, Corkscrew)
LAO20°CRA20°

HL
LCX
HL
①
②
③
①
②
③
LAD
D to #14
collateral (fair)
LCX
LM
Lesion Angle 140° ①
Predicted Occl. Length = 40mm
Eccentric calcification
at the ostium of CTO
Prox. Cap :
blunt
④
⑤
⑥
④
⑤
⑥
②③ ④ ⑤ ⑥
LCX
Eccentric calcification
at the ostium of CTO
LAO 25°CAU 35°

• Prox. Cap : blunt
• Occlu. Length : 40 mm
• Distal vessel : good quality
• Collaterals : good quality
• Severe calcification
• Tortuous and with OM branch
💡PLAN
・LAD intra-collateral
⇒ 8Fr TFA !! 8Fr GC !!
・Trial antegrade – brief
・Retrograde
Dept. of Cardiology, Tokyo General Hospital, Japan

Approach: Rt. Femoral A. 8Fr 40cm (long sheath)
Trial Antegrade approach
Dept. of Cardiology, Tokyo General Hospital, Japan
LAO 25°CAU 40°
Zizai ™ 135cm + XT-R
GAIA 1st
GAIA 2nd
GAIA 3rd
Guide catheter: 8Fr AL1.0 (SH)
RAO 35°CAU 20° For 20 minutes
💡 PLAN
Switched to Retrograde

Retrograde approach - apex channel via diagonal branch
Caravel MC 150 cm + SOUH03
Dept. of Cardiology, Tokyo General Hospital, Japan
Tip injection
For 60 minutes
LAO 30°CAU 30°
LAO 30°CAU 15°
RAO 30°CAU 20°
LAO 20°CAU 20°
LAO 25°CAU 35°

RAO 30°CAU 20°
Antegrade approach – 2nd try
Dept. of Cardiology, Tokyo General Hospital, Japan
ante.
retro.
CARAVEL MC + SUOH 03
XT-R, GAIA 2nd
Run through ultra floppy
8Fr AL1.0
Knuckle Wire Technique

LAO 25°CAU 20°
Antegrade approach – IVUS guided
Dept. of Cardiology, Tokyo General Hospital, Japan
ante.
retro.
Success !!
AnteOwl
SASUKE + XT-R
GAIA 1st
GAIA 2nd
GAIA 3rd
LAO 25°CAU 20°
For 40 minutes
CARAVEL MC +
Run through ultra floppy

Pre-IVUS findings
AnteOwl WR ™
subintimal
Dept. of Cardiology, Tokyo General Hospital, Japan

Dept. of Cardiology, Tokyo General Hospital, Japan
LAO 30°CRA 25°
LAO 15°CAU 25°
Pre-dilatation
SCB 2.0*15 mm

BP-SES 2.5*21 mm
Stenting and post-IVUS imaging
Dept. of Cardiology, Tokyo General Hospital, Japan
Post-IVUS imaging
BP-SES 2.25*38 mm
LAO 15°CAU 20°
LAO 20°CAU 20°
AnteOwl WR ™

LAO 10°CAU 20°
Final CAG
Dept. of Cardiology, Tokyo General Hospital, Japan
Procedure time : 145 mins
Radiation : 3.95 Gy
Contrast volume : 360 ml
RAO 25°CAU 20°

Summary
• Use 8Fr sheath and 8Fr guide catheter from Femoral Artery for retrograde CTO via LAD
intra collateral.
• When advancing the devices from retrograde, recommend to use a micro guide catheter
with strong core because you will need strong backup force.
• When two wires, antegrade and retrograde approach, were both in sub intimate space at the
rendezvous point, the Knuckle Wire Technique(KWT) is quite effective.
• If the entry and distal lumen are true intima, even if the middle portion is sub intimal, it is
acceptable.
Dept. of Cardiology, Tokyo General Hospital, Japan

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Successful Retrograde Approach PCI For The Ostium of LCX Chronic Total Occlusion (CTO) via an LAD intra-diagonal collateral channel.pptx

1. Successful Retrograde Approach PCI For The Ostium of LCX Chronic Total Occlusion (CTO) via an LAD intra-diagonal collateral channel Dept. of Cardiology, Tokyo General Hospital, Japan Yukihiro Yamaguchi, Reiko Tsukahara, Toshiya Muramatsu, Masatsugu Nakano, Hideyuki Takimura, Mami Kawano, Emi Tajima, Tsuzuki Ippei, Rintaro Taniguchi, Kurozumi Atsumasa 第59回 CVIT 関東甲信越地方会 2022

2. the Japanese Association of Cardiovascular Intervention and Therapeutics COI Disclosure Yukihiro Yamaguchi The authors have no financial conflicts of interest to disclose concerning the presentation.

3. RAO 30° CAU 20° ’21/9 PCI for LCX CTO  Diagnosis: SMI  Prior intervention: ’21/4 AP (seg.1-3 EES)  Coronary risk factor: HT, HL, OCI  eGFR: 70 (mL/min/1.73m2)  Syntax score: 18  J-CTO score: 3, J-Channel score: 5  LVEF 72.5％ (UCG) Dept. of Cardiology, Tokyo General Hospital, Japan LAO 25° CAU 35°

4. RAO 40°CAU 20° Dept. of Cardiology, Tokyo General Hospital, Japan LAO 25°CAU 35°

5. Retro channel - apex channel via diagonal branch Apex via diagonal branch J-channel score LAO30°CRA20° Dept. of Cardiology, Tokyo General Hospital, Japan 5 (Small, Reverse bend, Corkscrew) LAO20°CRA20°

6. HL LCX HL ① ② ③ ① ② ③ LAD D to #14 collateral (fair) LCX LM Lesion Angle 140° ① Predicted Occl. Length = 40mm Eccentric calcification at the ostium of CTO Prox. Cap : blunt ④ ⑤ ⑥ ④ ⑤ ⑥ ②③ ④ ⑤ ⑥ LCX Eccentric calcification at the ostium of CTO LAO 25°CAU 35°

7. • Prox. Cap : blunt • Occlu. Length : 40 mm • Distal vessel : good quality • Collaterals : good quality • Severe calcification • Tortuous and with OM branch 💡PLAN ・LAD intra-collateral ⇒ 8Fr TFA !! 8Fr GC !! ・Trial antegrade – brief ・Retrograde Dept. of Cardiology, Tokyo General Hospital, Japan

8. Approach: Rt. Femoral A. 8Fr 40cm (long sheath) Trial Antegrade approach Dept. of Cardiology, Tokyo General Hospital, Japan LAO 25°CAU 40° Zizai ™ 135cm + XT-R GAIA 1st GAIA 2nd GAIA 3rd Guide catheter: 8Fr AL1.0 (SH) RAO 35°CAU 20° For 20 minutes 💡 PLAN Switched to Retrograde

9. Retrograde approach - apex channel via diagonal branch Caravel MC 150 cm + SOUH03 Dept. of Cardiology, Tokyo General Hospital, Japan Tip injection For 60 minutes LAO 30°CAU 30° LAO 30°CAU 15° RAO 30°CAU 20° LAO 20°CAU 20° LAO 25°CAU 35°

10. RAO 30°CAU 20° Antegrade approach – 2nd try Dept. of Cardiology, Tokyo General Hospital, Japan ante. retro. CARAVEL MC + SUOH 03 XT-R, GAIA 2nd Run through ultra floppy 8Fr AL1.0 Knuckle Wire Technique

11. LAO 25°CAU 20° Antegrade approach – IVUS guided Dept. of Cardiology, Tokyo General Hospital, Japan ante. retro. Success !! AnteOwl SASUKE + XT-R GAIA 1st GAIA 2nd GAIA 3rd LAO 25°CAU 20° For 40 minutes CARAVEL MC + Run through ultra floppy

12. Pre-IVUS findings AnteOwl WR ™ subintimal Dept. of Cardiology, Tokyo General Hospital, Japan

13. Dept. of Cardiology, Tokyo General Hospital, Japan LAO 30°CRA 25° LAO 15°CAU 25° Pre-dilatation SCB 2.0*15 mm

14. BP-SES 2.5*21 mm Stenting and post-IVUS imaging Dept. of Cardiology, Tokyo General Hospital, Japan Post-IVUS imaging BP-SES 2.25*38 mm LAO 15°CAU 20° LAO 20°CAU 20° AnteOwl WR ™

15. LAO 10°CAU 20° Final CAG Dept. of Cardiology, Tokyo General Hospital, Japan Procedure time : 145 mins Radiation : 3.95 Gy Contrast volume : 360 ml RAO 25°CAU 20°

16. Summary • Use 8Fr sheath and 8Fr guide catheter from Femoral Artery for retrograde CTO via LAD intra collateral. • When advancing the devices from retrograde, recommend to use a micro guide catheter with strong core because you will need strong backup force. • When two wires, antegrade and retrograde approach, were both in sub intimate space at the rendezvous point, the Knuckle Wire Technique(KWT) is quite effective. • If the entry and distal lumen are true intima, even if the middle portion is sub intimal, it is acceptable. Dept. of Cardiology, Tokyo General Hospital, Japan

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