AUDITORIUM ZUBIN MEHTA 09/09/2023 10:00 - 11:10 PARALLEL SESSION - CHALLENGES AND OPPORTUNITIES IN CTO RECANALIZATION

1. Shunsuke Matsuno, MD
The Cardiovascular Institute, Japan
Intracoronary imaging guidance
in CTO practice

2. COI disclosure
• I DO NOT have any relevant financial relationships to disclose.

3. Role of intracoronary imaging in CTO PCI
• Facilitation of wire crossing
- Stumpless CTO
- Challenging reverse CART
- IVUS-guided rewiring or reentry
• Treatment optimization after wire crossing
- Determination of stent landing zone
- Stent optimization

4. Stumpless LAD CTO

5. IVUS pullback from adjacent septal branch

6. Real-time IVUS-guided proximal cap penetration w/ Gaia Next 2

7. IVUS pullback after proximal cap penetration

8. Successful antegrade wire crossing

9. Final angiography

10. Tips for IVUS-guided entry
• IVUS-guided entry is possible when there is a side branch sufficiently large to
accommodate an IVUS catheter and which is close to an ambiguous cap.
• IVUS reveals the plaque composition of the proximal cap, which helps us to
select wires and estimate the difficulty of puncture.
• Not only visualizing an occluded vessel but also confirming the wire position
after penetration is important: real-time IVUS guidance or IVUS confirmation
after puncture.

11. RCA CTO w/ vessel course ambiguity and bending

12. Failed antegrade wire escalation

13. Failed conventional reverse CART

14. IVUS examination
A
B
C
Ante: intraplaque
Retro: extra vessel
Ante: subintimal
Retro: subintimal
Ante: subintimal
Retro: Intraplaque
A
B
C
R
A
R
A
R
A

15. Successful reverse CART

16. Final angiography

17. Pattern A
Pattern B
Pattern C
Pattern D
Ante: intraplaque
Retro: intraplaque
Ante: subintimal
Retro: subintimal
Ante: intraplaque
Retro: subintimal
Ante: subintimal
Retro: intraplaque
• It is easy to make a connection after
antegrade balloon dilatation.
• Puncture with a penetrative retrograde wire
could be an option.
• It is easy to make a connection after
antegrade balloon dilatation.
• Retrograde wire is to be exchanged for a
more controllable wire.
• It is crucial to create a medial dissection
with a properly sized balloon dilatation.
• Advancing an antegrade wire or move-the-
cap techniques can be the next options.
• A retrograde wire should be advanced
proximally to make more favorable points.
• Retrograde penetration to a sized-up
antegrade balloon and the traditional CART
are other options.
A
R
A
R
A
R
A
R

18. LCX CTO w/o feasible retrograde options

19. XT-R migrated into a false lumen

20. IVUS examination

21. IVUS-guided rewiring w/ CP12ST

22. IVUS examination after rewiring

23. Wire de-escalation for XT-R

24. Final angiography

25. Tips for IVUS-guided rewiring or reentry
• IVUS reveals the appropriate rewiring point with less calcification or the most
appropriate reentry point that is not calcific and where the true lumen is not
extremely compressed.
• Co-registration of IVUS and fluoroscopic information is essential to know
where the second wire should be advanced.

26. LAD short CTO in patient w/ LVEF 22%

27. Successful reverse CART

28. Angiography after DES implantation

29. IVUS pullback from distal LAD

30. 2.5mm balloon dilatation

31. Final angiography

32. 3M after CTO PCI

33. IVUS examination after wire crossing
• As the distal vessel of the occlusion tends to shrink due to hypoperfusion,
angiographic evaluation alone can lead to an overestimation of disease and
extended stent length.
• IVUS clarifies the reasons for luminal narrowing (mainly by atherosclerotic
plaque or negative remodeling) and helps to determine the correct management.
• If the distal vessel is shrunk w/o much plaque, balloon dilatation alone or leaving it
is enough. DES will be needed if IVUS shows a high plaque burden w/o much
vessel shrinkage.

34. Conclusion
• IVUS provides information that is unavailable from angiography, resulting in
facilitation of wire crossing and procedure optimization after wire crossing.

35. Thank you for your kind attention.
Shunsuke Matsuno, MD
The Cardiovascular Institute
E-mail: matsuno@cvi.or.jp