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IVUS Guided CTO PCI
Fu Wai Hospital
Jie Qian
Different IVUS Catheter
Atlantis SR pro2 (Boston)Atlantis SR pro2 (Boston)
Eagle Eye (Volcano)Eagle Eye (Volcano)
IVUS Guided CTO PCI
• Wiring Technique
• Optimized CTO PCI
Antegrade Technique
• To detect the entry point
• Define true or false lumen
• To navigate guidewire from false lumen to true lumen
Finding entry point
micro catheter
guide wire
Case 1
Case 1
Lad come in
Case 1
Define true or false lumen
• Three layer structure
• Side branch
Case 2
Case 2
Case 2
Case 2
Wire hematoma
Huge hematoma
Huge dissection
Case 3
To navigate guidewire from false lumen to true lumen
Case 4True lumen
Re-entry point
Proximal
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
Case 5
Case 5
Case 5
Retrograde wire
Wire in plaque
Wire Out
Case 5
Case 6
Case 6
Case 6
Case 6
True lumen
Retrograde wire
Case 6
Hematoma
Case 6
IVUS Guided CTO PCI
• Wiring Technique
• Optimized CTO PCI
Ante group (n=23) Retro group (n=25)
p=0.50
p=0.49
0
10
20
30
40
50
60
70
Subintimalwiring
Intramuralcoronary
hematoma
Extramural
hematoma
IVUS-detectedcoronary
perforation
Angiographicextravazation
2(8%)
0 (0%)
11(44%)
6(26%)
3(12%)2
(9%)
p>0.996
(24%)
3(13%)
p=0.47
10(40%)
2(9%)
p=0.02
Inci
den
ce
(%
)
coronary
Comparison of Qualitative DataComparison of Qualitative Data
Tsujita JACC Interv 2009
Stent
LAD Plaque DistributionLAD Plaque Distribution
5 mm forward
5 mm radius
Field of View
• 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
FL.IVUS with RF TunnelingFL.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
Example of View
Investigational Device, not for human use
Summary ( 1 )• With suitable side branch, IVUS-guided wiring is helpful t
o 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.
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.
THANKS!
Case 7
Reverse CART with Stenting
Perivascular Hematoma
New Layer Formation
Perivascular Blood Speckle
IVUS findings Perivascular TraumaIVUS findings Perivascular Trauma
0.2
0.25
0.3
0.35
0.4
0.45
0.5
0 10 20 30 40 50 60 70 80
Distance from Ostium
Ave
rag
e P
laq
ue
Bu
rden
0.2
0.25
0.3
0.35
0.4
0.45
0.5
0 10 20 30 40 50 60 70 80 90 100
RCA
LAD
Ave
rag
e P
laq
ue
Bu
rden
(mm)
(mm)
(%)
(%)
Distance from Ostium
Plaque DistributionPlaque Distribution n=75
n=61