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IVUS Guided CTO PCI

IVUS Guided CTO PCI. Fu Wai Hospital Jie Qian. Atlantis SR pro2 (Boston). Eagle Eye (Volcano). Different IVUS Catheter. IVUS Guided CTO PCI. Wiring Technique Optimized CTO PCI. Antegrade Technique. To detect the entry point Define true or false lumen

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IVUS Guided CTO PCI

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  1. IVUS Guided CTO PCI Fu Wai Hospital Jie Qian

  2. Atlantis SR pro2 (Boston) Eagle Eye (Volcano) Different IVUS Catheter

  3. IVUS Guided CTO PCI • Wiring Technique • Optimized CTO PCI

  4. Antegrade Technique • To detect the entry point • Define true or false lumen • To navigate guidewire from false lumen to true lumen

  5. micro catheter guide wire Finding entry point

  6. Case 1

  7. Case 1 Lad come in

  8. Case 1

  9. Define true or false lumen • Three layer structure • Side branch

  10. Case 2

  11. Case 2

  12. Case 2

  13. Case 2 Huge hematoma Wire hematoma Huge dissection

  14. Case 3

  15. To navigate guidewire from false lumen to true lumen

  16. Case 4 True lumen Proximal Re-entry point

  17. Retrograde Technique Tracking the retrograde wire route and verify wire cross into true or false lumen Reverse CART ( or with stenting), assess proximal vessel size and decide balloon size

  18. Case 5

  19. Case 5

  20. Case 5 Wire in plaque Wire Out Retrograde wire

  21. Case 5

  22. Case 6

  23. Case 6

  24. Case 6

  25. Case 6 Retrograde wire True lumen

  26. Case 6 Hematoma

  27. Case 6

  28. IVUS Guided CTO PCI • Wiring Technique • Optimized CTO PCI

  29. Comparison of Qualitative Data Retro group (n=25) Ante group (n=23) 70 60 p=0.50 50 p=0.02 11 (44%) 40 Incidence (%) 10 (40%) p=0.47 30 6 (26%) 6 (24%) 20 p>0.99 p=0.49 10 3 (13%) 3 (12%) 2 (9%) 0 (0%) 2 (8%) 2 (9%) 0 Subintimal Intramural Extramural IVUS-detected Angiographic wiring coronary coronary coronary extravazation hematoma hematoma perforation Tsujita JACC Interv 2009

  30. Stent

  31. LAD Plaque Distribution

  32. Field of View 5 mm forward 5 mm radius 5 mm forward 1 mm • 5 mm to the side • “Tick marks” are 1 mm in cross-sectional plane for easy diameter sizing • This artery measures 9 mm Investigational Device, not for human use

  33. FL.IVUS with RF Tunneling FL.IVUS with RF Tunneling designed to provide: CTO Visualization IVUS imaging will show proximal CTO cap and vessel borders and position of catheter within lesion Steering Rotating the tip of the catheter will direct the RF electrode to desired target Angled RF beam will allow operator to steer away from vessel walls Lesion penetration RF waves will ablate tissue allowing tunneling through lesion Investigational Device, not for human use

  34. Example of View Investigational Device, not for human use

  35. Summary（1） • With suitable side branch, IVUS-guided wiring is helpful to find entry point in no stump CTO lesions. • Define true or false lumen can help to decide stenting or not. It also can help to find true and false lumen crossover point, navigate wire from false to true lumen. • In retrograde technique, IVUS is a very helpful tool especially in Retrograde Wire Cross and Reverse CART (or stenting). • To get successful result in CTO-PCI, we should be familiar with IVUS imaging of CTO and use it with proper way.

  36. Summary （2） • CTO procedure (especially retrograde approach) cause perivascular trauma which can be detected by IVUS, though angiographically silent. • Distal coronary artery spares plaque accumulation and IVUS can help to decide the stent landing area.

  37. THANKS!

  38. Case 7

  39. Reverse CART with Stenting

  40. Perivascular Blood Speckle New Layer Formation Perivascular Hematoma IVUS findings Perivascular Trauma

  41. 0.5 0.45 0.4 0.35 0.3 0.25 0.2 0 10 20 30 40 50 60 70 80 0.5 0.45 0.4 0.35 0.3 0.25 0.2 0 10 20 30 40 50 60 70 80 90 100 Plaque Distribution (%) LAD n=75 Average Plaque Burden (mm) Distance from Ostium (%) RCA n=61 Average Plaque Burden (mm) Distance from Ostium

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