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Friday 1200 – tsuchikane - retrograde std and cart approach

Experts "Live" CTO Workshop 2015 Septemper, 18th – 19th , 2014 in Istanbul, Turkey

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Friday 1200 – tsuchikane - retrograde std and cart approach

  1. 1. CTO Toyohashi Heart Center Retrograde std and CART approach, New micros, and specific devices to increase support or to penetrate Etsuo Tsuchikane, MD, PhD Toyohashi Heart Center Nagoya Heart Center Gifu Heart Center
  2. 2. CTO Toyohashi Heart Center 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. 3. CTO Toyohashi Heart Center Agenda 1. New devices for retrograde channel crossing 2. Contemporary retrograde CTO crossing 3. Specific devices for antegrade penetration
  4. 4. CTO Toyohashi Heart Center Agenda 1. New devices for retrograde channel crossing 2. Contemporary retrograde CTO crossing 3. Specific devices for antegrade penetration
  5. 5. Collateral channel crossing 48% 19% 11% 10% 11% SION XT-R SION blue Fielder FC SUOH SION black other 2012 61 % 18 % 7% 60% 26% 7% Septal Epicardial AC Ipsilateral Bypass graft 68 % 17 % 7% 2013 Total (1329) 2012 (490) 2013 (538) 2014 (301) P Guidewire cross success 77% (1025) 78% (380) 76%(411) 78%(234) 0.8702 2012 2013 Successful guidewire Successful collateral route 69 % 18 % 7% 2014 54 % 9% 7% 11 % 2014 Channel cross success rate
  6. 6. Toyohashi Heart CenterCTO The 1st step of retrograde approach is the collateral channel wire crossing
  7. 7. Toyohashi Heart CenterCTO Reason why collateral channel crossing is difficult Small side branch at a bend of the artery Acute bend Continuous tortuosity Invisible branch
  8. 8. Toyohashi Heart CenterCTO Understand the necessity of guide wire performance in each situation Small side branch at a bend of the artery Acute bend Continuous tortuosity Invisible branch  Torque ability  Tip lubricity  Tip flexibility  Tip lubricity  Push transmission  Tip flexibility  Tip lubricity  Tiny tip curve Lower tip profile  Tip lubricity
  9. 9. Toyohashi Heart CenterCTO Epicardial channel Continuous tortuosity Wire automatically go into small side branch at a bend of the artery Acute bend  maneuverability  lubricity  maneuverability  lubricity  tip flexibility  lubricity SION SUOH03 SION
  10. 10. Toyohashi Heart CenterCTO Acute bend  tip flexibility  lubricity SUOH03 Epicardial channel
  11. 11. Toyohashi Heart CenterCTO  Coating: Full Hydrophilic Coating 52cm  Usable Length 190cm  Radiopaque Length 3cm  Tip Load 0.3gf  Tip Shape Straight/ Pre-shape ASAHI SUOH 03 Specification Radiopaque length: 3cm Hydrophilic coating: 52cm SLIP-COAT®
  12. 12. Toyohashi Heart CenterCTO ASAHI SUOH03 is a very flexible wire from the tip to distal. It becomes easy to cross the small bended vessel by increasing its trackability. ASAHI SUOH 03 Specification Tip FlexibilityTip Load(gf) Distance from the tip(mm) High Stiffness
  13. 13. Toyohashi Heart CenterCTO Collateral channel crossing Guidewire selection for complex channel tracking Anatomy Recommendable GW Septal Epicardial Continuous tortuosity ①SION ②SUOH 03 ③XT-R ①SUOH 03 ②SION ③XT-R (if a small channel) SION black (if a large channel) Small side branch at a bend of the artery ①SION ②SUOH 03 ③XT-R (if a small main vessel) SION black (if a large main vessel) ①SUOH 03 ②SION ③XT-R (if a small main vessel) SION black (if a large main vessel) Acute bend ①SUOH 03 ②SION ③SION black ①SUOH 03 ②SION ③SION black Crossing invisible channel ①XT-R ②SION black ③SION Don`t touch Performance which is need Recommendable 1st.GW Septal Maneuverability To select side branch SION Epicardial Tip flexibility To avoid perforation SUOH 03
  14. 14. Toyohashi Heart CenterCTO Proximal LAD CTO, 2nd Attempt
  15. 15. Toyohashi Heart CenterCTO Epicardial channel from LCx to Dx2
  16. 16. Toyohashi Heart CenterCTO Channel tracking with SUOH03
  17. 17. Toyohashi Heart CenterCTO Coil embolization
  18. 18. Toyohashi Heart CenterCTO AC channel Proximal RCA CTO, 2nd Attempt
  19. 19. Toyohashi Heart CenterCTO RA before retrograde access
  20. 20. Toyohashi Heart CenterCTO Tip Injection
  21. 21. Toyohashi Heart CenterCTO SUOH03 crossed, but Corsair didn’t…
  22. 22. Toyohashi Heart CenterCTO Caravel 135
  23. 23. Toyohashi Heart CenterCTO Final angiogram
  24. 24. 24 ⒸASAHI INTECC CO., LTD 2014; This document is for training of staff and contains confidential or privileged information. Any distribution, copying, forwarding or citation is strictly prohibited. Product structure Hydrophilic coating: 75cm Caravel Prox. 0.55mm 0.85mm PTFE Products Length Coating LengthEntry Distal Proximal Entry Distal Proximal ASAHI Caravel 0.48 mm (1.4 Fr) 0.62 mm (1.9 Fr) 0.85 mm (2.6 Fr) 0.40 mm (0.016inch) 0.43 mm (0.017inch) 0.55 mm (0.022inch) 135cm 75cm ASAHI Corsair 0.42 mm (1.3 Fr) 0.87 mm (2.6 Fr) 0.93 mm (2.8 Fr) 0.38 mm (0.015inch) 0.45 mm (0.018inch) 0.45 mm (0.018inch) 135cm 150cm 60cm 0.62mm Caravel Dis. 0.43mm PTFE
  25. 25. Toyohashi Heart CenterCTO Antegrade C12 went outside… Mid LAD CTO, 2nd Attempt
  26. 26. Toyohashi Heart CenterCTO CTO exit Tip injection
  27. 27. Toyohashi Heart CenterCTO XTR crossed, but Corsair didn’t… Caravel easily crossed! Tip of Caravel
  28. 28. Toyohashi Heart CenterCTO GAIA 2nd puncture! Contemporary reverse CART Final angiogram
  29. 29. CTO Toyohashi Heart Center Agenda 1. New devices for retrograde channel crossing 2. Contemporary retrograde CTO crossing 3. Specific devices for antegrade penetration SUOH03, Caravel microcatheter
  30. 30. CTO Toyohashi Heart Center Agenda 1. New devices for retrograde channel crossing 2. Contemporary retrograde CTO crossing 3. Specific devices for antegrade penetration SUOH03, Caravel microcatheter
  31. 31. 51% 35% 14% 1% 61% 26% 13% 1% 0% 20% 40% 60% Reverse CART Retrogradewire cross Kissing wire cross CART 2012 2013 Sumitsuji et al. JACC Cardiovasc Interv 2011 Patterns of Success in Retrograde Approach Procedure characteristics (3) CTO crossing Total (1028) 2012 (490) 2013 (538) P Guidewire cross 65.5% (673) 69.0% (338) 62.3%(335) 0.0033
  32. 32. Guidewire for CTO crossing (1) Retrograde cases Reverse CART 29% 16% 12% 8% 8% 7% 21% FFC SION ULTIM3 XT-R Gaia 1 Gaia 2 other 30% 15% 13% 10% 6% 27% Gaia 2 SION ULTIM3 Gaia 1 XT-R Other Retrograde wire cross 25% 11% 10% 9% 7% 7% 31% ULTIM3 FFC ConPro Gaia 1 XT-R Gaia 2 other 27% 19% 13% 11% 5% 25% Gaia 2 Gaia 1 ULTIM3 SION XT-R other P<0.05 2012 2013 2012 2013
  33. 33. Kissing wire cross 36% 16%10% 7% 32% ConPro Gaia 1 Gaia 2 ULTIM3 other 33% 30% 10% 10% 17% Gaia 2 ConPro Gaia 1 Gaia 3 Other P<0.05 2012 2013 Guidewire for CTO crossing (2) Retrograde cases
  34. 34. Toyohashi Heart CenterCTO Mid RCA CTO, 2nd Attempt
  35. 35. Toyohashi Heart CenterCTO RA 1.5 Before antegrade preparation…
  36. 36. Toyohashi Heart CenterCTO Ultimate 3 Crusade Antegrade preparation with non-tapered wire in DLC
  37. 37. Toyohashi Heart CenterCTO occlusion RV wire Ultimate 3 outside vessel!
  38. 38. Toyohashi Heart CenterCTO GAIA 2 Contemporary reverse CART
  39. 39. Toyohashi Heart CenterCTO EES 2.5*28 Extravasation! After EES implantation
  40. 40. Toyohashi Heart CenterCTO BVS 3*28 7Fr Guideliner Long BVS delivery through Guideliner
  41. 41. Toyohashi Heart CenterCTO BVS 3.5*18 EES 3.5*23 Another BVS and EES delivery
  42. 42. Toyohashi Heart CenterCTO Final angiogram
  43. 43. Toyohashi Heart CenterCTO Mid RCA CTO, 2nd Attempt
  44. 44. Toyohashi Heart CenterCTO Traditional bilateral wiringGuideliner DeliveryGuideliner reverse CART 7Fr Guideliner Final angiogram
  45. 45. Toyohashi Heart CenterCTO Limitations of Contemporary Reverse CART  Short CTOs  Long CTOs w/wo ambiguous vessel course  Impossible case  Difficult antegrade ballooning for rCART
  46. 46. CTO Toyohashi Heart Center RCA CTO
  47. 47. CTO Toyohashi Heart Center Difficult for reverse CART because of short occlusion
  48. 48. CTO Toyohashi Heart Center Attempt at retrograde direct wire crossing by GAIA 2nd
  49. 49. CTO Toyohashi Heart Center Successful retrograde wire crossing by GAIA 2ndManipulation of GAIA 2nd
  50. 50. CTO Toyohashi Heart Center Final angiogram
  51. 51. Toyohashi Heart CenterCTO Limitations of Contemporary Reverse CART  Short CTOs  Long CTOs w/wo ambiguous vessel course  Impossible case  Difficult antegrade ballooning for rCART  Careless antegrade preparation is dangerous!
  52. 52. CTO Toyohashi Heart Center RCA CTO
  53. 53. CTO Toyohashi Heart Center Simultaneous injection
  54. 54. CTO Toyohashi Heart Center Antegrade wiring using GAIA 2nd
  55. 55. CTO Toyohashi Heart Center Antegrade GAIA looks outside the vessel…
  56. 56. CTO Toyohashi Heart Center Retrograde wiring using Ultimate 3
  57. 57. CTO Toyohashi Heart Center Successful reverse CART
  58. 58. CTO Toyohashi Heart Center Type 1 perforation
  59. 59. Toyohashi Heart CenterCTO Limitations of Contemporary Reverse CART  Short CTOs  Long CTOs w/wo ambiguous vessel course  Impossible case  Difficult antegrade ballooning for rCART  Careless antegrade preparation is dangerous!  Still we need non-tapered wire or knuckle wire
  60. 60. CTO Toyohashi Heart Center calcification
  61. 61. CTO Toyohashi Heart Center
  62. 62. CTO Toyohashi Heart Center Calcification disturbed retrograde direct crossing and kissing wire.
  63. 63. CTO Toyohashi Heart Center Calcification disturbed retrograde knuckle wiring.
  64. 64. CTO Toyohashi Heart Center Calcification disturbed antegrade balloon crossing. diffuse plaque Impossible reverse CART!
  65. 65. CTO Toyohashi Heart Center Original CART!
  66. 66. CTO Toyohashi Heart Center Retrograde balloon trapping enabled antegrade balloon crossing. antegrade balloon
  67. 67. CTO Toyohashi Heart Center Final angiogram
  68. 68. Toyohashi Heart CenterCTO Limitations of Contemporary Reverse CART  Short CTOs  Long CTOs w/wo ambiguous vessel course  Impossible case  Difficult antegrade ballooning for rCART  Careless antegrade preparation is dangerous!  Still we need non-tapered wire or knuckle wire  Traditional CART
  69. 69. CTO Toyohashi Heart Center Agenda 1. New devices for retrograde channel crossing 2. Contemporary retrograde CTO crossing 3. Specific devices for antegrade penetration SUOH03, Caravel microcatheter Mainly reverse CART, but don’t forget CART!
  70. 70. CTO Toyohashi Heart Center Agenda 1. New devices for retrograde channel crossing 2. Contemporary retrograde CTO crossing 3. Specific devices for antegrade penetration SUOH03, Caravel microcatheter Mainly reverse CART, but don’t forget CART!
  71. 71. CTO Toyohashi Heart Center Multifunction Catheter having two Guidewire lumen (RX / OTW) for Side Branch Access; especially helpful for GW manipulation in Bifurcation Stenting procedure
  72. 72. CTO Toyohashi Heart Center Use of Double Lumen Catheter (DLC) In CTO-PCI  Antegrade approcah 1. Increase penetration force 2. Change penetration position 3. Parallel wiring 4. Retrieve side branch 5. Reverse wiring 6. Side branch technique  Retrograde approcah 1. Second system through collateral channel
  73. 73. CTO Toyohashi Heart Center The outcome of the evaluation - Guidewire support - Floppy Stiff (courtesy of Dr. Ochiai)
  74. 74. CTO Toyohashi Heart Center Use of Double Lumen Catheter (DLC) In CTO-PCI  Antegrade approcah 1. Increase penetration force 2. Change penetration position 3. Parallel wiring 4. Retrieve side branch 5. Reverse wiring 6. Side branch technique  Retrograde approcah 1. Second system through collateral channel
  75. 75. CTO Toyohashi Heart Center Case: Proximal LAD-CTO
  76. 76. CTO Toyohashi Heart Center GAIA with Corsair
  77. 77. CTO Toyohashi Heart Center Crusade in proximal branch
  78. 78. CTO Toyohashi Heart Center GAIA with Crusade GAIA with Corsair
  79. 79. CTO Toyohashi Heart Center GAIA with Crusade
  80. 80. CTO Toyohashi Heart Center GAIA in diagonal branch
  81. 81. CTO Toyohashi Heart Center Final angiogram
  82. 82. CTO Toyohashi Heart Center Use of Double Lumen Catheter (DLC) In CTO-PCI  Antegrade approcah 1. Increase penetration force 2. Change penetration position 3. Parallel wiring 4. Retrieve side branch 5. Reverse wiring 6. Side branch technique  Retrograde approcah 1. Second system through collateral channel
  83. 83. CTO Toyohashi Heart Center Case: Proximal LCx tandem CTOs
  84. 84. CTO Toyohashi Heart Center GAIA with Corsair
  85. 85. CTO Toyohashi Heart Center GAIA with Caravel in subintimal space
  86. 86. CTO Toyohashi Heart Center Another GAIA with Crusade (parallel wiring)
  87. 87. CTO Toyohashi Heart Center Successful parallel wiring
  88. 88. CTO Toyohashi Heart Center Final angiogram
  89. 89. CTO Toyohashi Heart Center The outcome of the evaluation Guidewire Support (courtesy of Dr. Ochiai)
  90. 90. CTO Toyohashi Heart Center Use of Double Lumen Catheter (DLC) In CTO-PCI  Antegrade approcah 1. Increase penetration force 2. Change penetration position 3. Parallel wiring 4. Retrieve side branch 5. Reverse wiring 6. Side branch technique  Retrograde approcah 1. Second system through collateral channel Advantage The 1st wire is quite stable. Penetration force of the 2nd wire becomes higher. Disadvantage Predilatation is sometimes required. Seesaw wiring is unavailable.
  91. 91. CTO Toyohashi Heart Center Agenda 1. New devices for retrograde channel crossing 2. Contemporary retrograde CTO crossing 3. Specific devices for antegrade penetration SUOH03, Caravel microcatheter Mainly reverse CART, but don’t forget CART! Double lumen microcatheter
  92. 92. Toyohashi Heart CenterCTO 17th CTO Club June 17-18, 2016, Nagoya, Japan www.cct.gr.jp/ctoclub
  93. 93. Toyohashi Heart CenterCTO Collateral channel crossing Guide wire selection for complex channel tracking Anatomy Performance which is need Recommendable GW Septal Epicardial Continuous tortuosity  maneuverability  tip flexibility  lubricity ①SION ②SUOH 03 ③XT-R ①SUOH 03 ②SION ③XT-R (if a small channel ) SION black (if a large channel) Small side branch at a bend of the artery  non tapered tip  maneuverability  lubricity ①SION ②SUOH 03 ③XT-R (if a small main vessel ) SION black (if a large main vessel) ①SUOH 03 ②SION ③XT-R (if a small main vessel ) SION black (if a large main vessel) Acute bend  tip flexibility  lubricity  maneuverability ①SUOH 03 ②SION ③SION black ①SUOH 03 ②SION ③SION black Crossing invisible branch  low tip profile  lubricity  tip flexibility ①XT-R ②SION black ③SION Don`t touch Performance which is need Recommendable 1st.GW Septal Maneuverability To select side branch SION Epicardial Tip flexibility To avoid perforation SUOH 03
  94. 94. Toyohashi Heart CenterCTO RCA tandem CTOs, 2nd Attempt
  95. 95. Toyohashi Heart CenterCTO Epicardial channel SUOH03 Corsair/Finecross failed…
  96. 96. Toyohashi Heart CenterCTO Caravel easily crossed without anchoring. Final angiogram Finecross 150 followed.
  97. 97. Toyohashi Heart CenterCTO CTO length 28.87mm CPR Proximal LAD CTO, 2nd Attempt
  98. 98. Toyohashi Heart CenterCTO Fielder FC with Corsair
  99. 99. Toyohashi Heart CenterCTO Tip Injection
  100. 100. Toyohashi Heart CenterCTO SION crossed, but Corsair didn’t…
  101. 101. Toyohashi Heart CenterCTO Caravel 135
  102. 102. Toyohashi Heart CenterCTO Finecross 150
  103. 103. Toyohashi Heart CenterCTO Final angiogram

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