This document provides tips and tricks for treating chronic total occlusions (CTOs). It discusses: 1. The challenges of CTOs including bending, calcification, long lesions, and complex entry/exit points. 2. The need to select devices appropriately for each case, including guidewires tailored for different lesion characteristics and IVUS guidance. 3. Techniques for using different guidewire types to penetrate microchannels, modify calcified/bending lesions, and penetrate hard lesions. 4. The importance of selecting the right retrograde channel and devices, with the goal of making an antegrade-retrograde connection, as in traditional retrograde techniques. 5. Encourage

1. Tips & Tricks
for CTO intervention
Fuminobu Yoshimachi MD, PhD
Tokai University School of Medicine

2. Problems of Treating CTO
bending
calcification
long lesion
bifurcation
entry
exit
CTO is has various
pathological characters,
therefor sometimes it is
difficult to get success.

3. Problems of Treating CTO
bending
long lesion
bifurcation
entry
calcification
exit
CTO is complex lesion
II
Combination of device selection is needed

4. antegrade approach
Our devices on antegrade approach for CTO are
GuidWires and support catheters.
Sometimes, we need IVUS Guided PCI to check
entry point of occlusion or to control the
GuideWire to insert true lumen.
We have to change the devices according to the
lesion.

5. Guide Wire for treating CTO
XTR
Wizard 78
GAIA series
Miracle
Wizard 3
confianza
1. eel type: soft & floppy
The GW can pass through “Micro
channel” or “ loose tissue”
2. Knife type: good torque performance
The GW can be controlled intentionally,
but making space & modification to
the tissue .
3. spear type: stiff & taper
penetration to straight way

6. Coronary CT
Coronary CT is good for checking not only
occlusion but character of the lesion including
eccentrically-located calcification.

7. Micro Channel in CTO
160~230 μm = 0.16~0.23 mm
60～70% in CTO lesion
tapered > abrupt type
Short > long lesion
Sakuda H et al
Am J Pathol 1992:141(6):1507-16
Katsuragawa M et al.
J Am Coll Cardiol. 1993 Mar 1;21(3):604-11
Kumamoto M et al
Hum Pathol. 1995 Apr;26(4):450-6
Srivatsa SS et al.
Am Coll Cardiol. 1997 Apr;29(5):955-63
Carlino M et al
Catheter Cardiovasc Interv. 2008 Jan 1;71(1):20-6

8. Treating Micro Channel / Loose Tissue
- Soft and tapered GuideWire -
Micro Channel
loose tissue tracking

9. Treating bending & calcified lesion
- controllable GuideWire -
Making space and modifying the tissue by
the GW, sometimes it makes big dissection
lumen.

10. Treating hard lesion
- penetration GuideWire -
Hard and stiff tapered GW makes small
space.
But it goes straight , and it is difficult to
control the direction.

11. high & anterior take-off orifice of RCA

12. Wizard 78

13. tornus

14. Sapphire 1.0mm

15. TREK 2.0x15mm

16. Eagle Eye Platinum

17. Xience Prime 2.5x38mm

18. TREK 3.0x15mm

20. It is easy to engage to abnormal orifice of RCA
with Slender Catheter, and getting successful
for CTO lesion with some GWs & devices.

22. Wizard 78

23. LAXA 3.0x15mm

24. iBP 3.5x10mm

25. Resolute Integrity 3.5x38mm

26. corsair & Wizard78

27. conquest 8-20

28. Gaia 2nd

29. corsair

30. not cross!
Safire 1.0x6mm
&
rapture

31. Rotablator 1.5mm

32. KAMUI 3.0x15mm

34. Opticross

35. LAXA 4.0x10mm

36. Resolute Integrity 3.5x34mm

37. Ikazuchi Rev.1.25x10mm

39. retrograde approach
1. channel selection
septal channel
apex channel
epicald channel
2. device selection
GW
support catheter
3. how to make the ante-retro connection
same as TFI

40. retrograde approach
The most important essence for retrograde
approach is to confirm and select retrograde
channel, and to select effective device to pass the
channel.
main branch
small channel
same as TFI

41. Wizard3
rt. radial approach, SL 4.0 5Fr

42. XTR & Corsair

43. Retrograde approach with single GC is possible.

44. SL4.0 5Fr

45. Corsair & Wizard 78

46. Corsair & conquest 8-20

47. bilateral TRI

48. bilateral TRI

49. bilateral TRI

50. Retrograde approach via lt. & rt. radial
artery is possible !

51. Retrograde approach via lt. & rt. radial
artery is possible !

52. Take Home Massage
CTO is complex lesion with calcification, long diffuse
bending ....and so on.
To treat CTO, we have to select GuideWire ,support
catheter and other devices, and adjust the PCI style to
the situation.
The essence of treating CTO including retro grade
approach is the same as the TFI with big diameter GC.
There is no limitation on TRI to treat CTO even if using
a 5Fr GC.

53. Take Home Massage
Why don’t you hesitate TRI for CTO ?
Limitation is just in your mind !