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