8th Experts Live CTO Workshop 2016, September, 30th - October 1st, 2016 in Krakow, Poland

1. Intracoronary imaging in CTOs
When to use, how to use and
how to interpret the images
Philip Dingli MD
Javier Escaned MD PhD
Hospital Clinico San Carlos
Madrid
Spain

2. Key imaging patterns in using IVUS in CTOs:
our terminology at HCSC
Planets Kidneys Wires

3. How can IVUS aid in CTO´s? A personal list
• IVUS-guided ostial CTO wiring
• Reverse CART balloon sizing
• CART/ADR guidance (no
injections)
• IVUS-guided re-entry
• Assessment of distal vessel
• Optimization of stenting
• Management of complications
• Reduction in contrast use

4. How can IVUS aid in CTO´s? A personal list
• IVUS-guided ostial CTO wiring
• Reverse CART balloon sizing
• CART/ADR guidance (no
injections)
• IVUS-guided re-entry
• Assessment of distal vessel
• Optimization of stenting
• Management of complications
• Reduction in contrast use

5. Basic Principle
1. Choice of Branch
2. Choice of IVUS
3. Choice of CTO wire
IVUS guided wiring

7. How can IVUS aid in CTO´s? A personal list
• IVUS-guided ostial CTO wiring
• Reverse CART balloon sizing
• CART/ADR guidance (no
injections)
• IVUS-guided re-entry
• Assessment of distal vessel
• Optimization of stenting
• Management of complications
• Reduction in contrast use

8. Reverse
CART
IVUS imaging in reverse CART

9. Balloon sizing with
IVUS to maximise
subintimal space
and to facilitate
entry of retrograde
wire
Ensuring with IVUS
that retrograde wire
guidewire is within
antegrade lumen
IVUS imaging in reverse CART

10. How can IVUS aid in CTO´s? A personal list
• IVUS-guided ostial CTO wiring
• Reverse CART balloon sizing
• CART/ADR guidance (no
injections)
• IVUS-guided re-entry
• Assessment of distal vessel
• Optimization of stenting
• Management of complications
• Reduction in contrast use

12. • Limited room for
guidewire maneuvering.
• Lack of spatial
orientation.
• Target is a compressed /
collapsed part of the
vessel
Challenges for IVUS-guided re-entry

13.  Work in the angiographic angulation
showing the largest distance between
IVUS probe and working wire.
 Apply the same principle to
contralateral distal vessel
opacification
 Use a wire with high steerability and
tip control to re-enter
 Correlate your IVUS and angiographic
images as much as possible
Tips for IVUS-guided re-entry

14. Correlating IVUS and Angio Images
Yamane M / Coronary Stenosis. Imaging, Structure and Physiology / PCR Books

15. Tips for IVUS-guided re-entry
Yamane M / Coronary Stenosis. Imaging, Structure and Physiology / PCR Books

16. Subintimal track Stented subintimal track
Identifying subintimal track before and
after stenting

17. How can IVUS aid in CTO´s? A personal list
• IVUS-guided ostial CTO wiring
• Reverse CART balloon sizing
• CART/ADR guidance (no
injections)
• IVUS-guided re-entry
• Assessment of distal vessel
• Optimization of stenting
• Management of complications
• Reduction in contrast use

19. Angio-IVUS co-registration after
IVUS-guided wiring

21. A
B
C
A
B
C
Assessment of distal vessel

23. • Small distal vessel size with
negative remodelling
predicted by MSCT.
• Identification of CTO ostium
with MSCT.
• Guidance with IVUS.
• Favorable CTO
characteristics(absence of
calcium, no tortuosity).
Learning messages from this case

24. How can IVUS aid in CTO´s? A personal list
• IVUS-guided ostial CTO wiring
• Reverse CART balloon sizing
• CART/ADR guidance (no
injections)
• IVUS-guided re-entry
• Assessment of distal vessel
• Optimization of stenting
• Management and prevention of
complications
• Reduction in contrast use

26. Learning messages from this case
• Understanding ambiguous angiographic result of CTO PCI
• Optimization of stenting in complex PCI

27. • Superb visualisation of endoluminal surface and implanted
stents
• Providing valuable clues on long-term results of CTO PCI.
• Limited by the need of contrast administration (avoidance
of CIN in CTO patients is a major issue).
• Cannot be used by guidance without injections (a problem
in CART)
A word on OCT in chronic total occlusions

28. Use of Intravascular Imaging
During Chronic Total O
• 619 CTO percutaneous coronary interventions
performed between 2012 and 2015 at 7 US centers
• Intravascular imaging in 38%
• IVUS was used in 67% of retrograde vs 31% of
antegrade-only cases (P<0.0001).
( J Am Heart Assoc. 2016;5: e003890 doi: 10.1161/JAHA.116.003890)

29. • Stent sizing : 26.3%
• Stent optimization : 38.0%
• CTO crossing : 35.7%
– Antegrade : 27.9%
– Retrograde : 7.8%
• Imaging for crossing was used more commonly with:
– proximal cap ambiguity (49% versus 26%, p<0.0001)
– side branch at the proximal cap (61% versus 47%, p=0.035),
– blunt/no stump (68% versus 55%, P=0.009)
– longer occlusion length (30 mm [IQR: 22, 50] versus 28 mm [15, 44],
p=0.009)
– Higher JCTO (2.8 vs 2.4, p=0.001) and Progress CTO
( J Am Heart Assoc. 2016;5: e003890 doi: 10.1161/JAHA.116.003890)

30. • Similar success
• Similar MACE (2.7% versus 3.2%, p=0.772)
• Longer procedure
– 192 min [IQR 130, 255] vs 131 min [90, 192], p<0.0001
• Longer fluoroscopy
– 71 min [44, 93] vs 39 min [25, 69], P<0.0001
• Higher mean air kerma radiation dose
– 4.98 Gray [3.11, 6.04] versus 3.42 Gray [2.09, 5.09], P<0.0001
• More median contrast volume
– 310 mL [240, 400] versus 270 mL [200, 360], p=0.004
• Trend toward larger number of stents
– (2.71.3 versus 2.51.2, P=0.07)
( J Am Heart Assoc. 2016;5: e003890 doi: 10.1161/JAHA.116.003890)

31. Kang J et al PLoS One. 2015 Oct 14;10(10):e0140421
126 patients who underwent DES stenting, and post-PCI IVUS of CTO lesions
IVUS-based post-PCI MLD (<2.4 mm) and stent expansion ratio (≤70%)
values seem to be predictors of ISR in CTO stenting
Does IVUS influence outcomes in CTO PCI?

32. 402 patients with CTOs randomized to IVUS-guided and angiography-guided
groups. Secondarily randomized to ZES or BES.
Kim BK et al Circ Cardiovasc Interv. 2015;8:e002592.
Does IVUS influence outcomes in CTO PCI?

33. Tian et al. EuroIntervention 2015;10:1409-1417
• 230 patients
• Recanalised CTO lesion
• Randomised to IVUS-guided or
the angiography-guided
• The use of IVUS for penetration
of the true lumen and
optimisation of stent expansion
was only done in the IVUS-
guided group.
• Followed with office visits or
telephone contact up to 24
months.

34. Saito S et al Am J Cardiol 2016;117:727e734)
In 8 vessels in whom the stent was implanted into a subintimal space
maximum percent neointimal hyperplasia and minimum lumen area was
similar in the subintimal segment compared with the adjacent intraplaque
segment.
Does stenting the subintimal space
influence outcomes in CTO PCI?

35. Available at the PCR Bookshop at prconline.com
Coronary Stenosis: Imaging, Structure and Physiology
Additional information on topics
covered in this presentation

36. Thank You

37. ( J Am Heart Assoc. 2016;5: e003890 doi: 10.1161/JAHA.116.003890)

38. Intravascular Imaging and Contrast
Use

39. Mechanical vs Electronic Scans