CTO Recanalization Highlights from TOPIC Meeting Masahiko Ochiai MD, FACC, FESC, FSCAI Division of Cardiology Showa University Northern Yokohama Hospital, Kanagawa, JAPAN Dartmouth Medical College, Hanover, NH, USA

Disclosure Statement of Financial Interest Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below. Affiliation/Financial Relationship Company Lecture Fees Abbott Vascular, Asahi Intecc Co, Boston Scientific, Terumo Co.,

In TOPIC 2010, we had very active discussion about the terminology of CTO PCI based on the pathological and IVUS findings.

Interventional Definition of Intimal and Sub-intimal Spaces

Speculated Etiogy of CTO Thrombotic occlusion in a coronary artery →Progression of occlusion up to the proximal or distal side branches with blood flow → 1) Changes in the component of occlusion 2) Formation of micro-channels in the residual loose tissue

VH Analysis of CTO proximal reference distal reference

Evolution of CTO: extension and organization of the thrombus Courtesy of Dr S Sumitsuji

Progression of CTO Srivatsa S. et at. JACC Vol . 29, No. 5 1997: 955-63

Histopathologic Data A tapered and short CTO is feasible for PCI Katsuragawa M. et at. JACC Vol . 21, No. 3 1993: 604-11

AP, 62years, female: Mid RCA CTO 8Fr Mach1 FR3.5-SH

Conquest Pro in the Sub-intimal Space

Compression of the Distal True Lumen by the Hematoma

IVUS Examination from the Sub-intimal Space

Intimal and Subintimal Space due to Histopathologic Examination 4 3 2 1 True lumen 1 2 Intima 3 Subintima 4 Extra coronary 4 3 2 Courtesy of Dr S Sumitsuji

Subintimal Space is Expandable (transverse & longitudinal) Courtesy of Dr S Sumitsuji

Re-entry into the Distal Vessel Lumen is Really Difficult Courtesy of Dr S Sumitsuji

Key of Successful Antegrade Wiring is “Intima Tracking” Courtesy of Dr S Sumitsuji

IVUS Examination from the Sub-intimal Space Sono-lucent Zone

Conquest Pro 12gr under IVUS Guidance in the “Intimal Space” of RCA Sono-lucent Zone

calcification and tortuosity inside the CTO

Antegrade “Loose Tissue” Tracking

Antegrade Intentional Intimal Tracking CTO without Any Loose Tissue

Imagine what’s happening inside the CTO body! Antegrade Loose Tissue Tracking Intentional Intimal Tracking beyond the Resistant Point

Terminology in Retrograde Approach

Definition of CART CART: Controlled Antegrade and Retrograde sub-intimal Tracking “Sub-intimal” space can be detected only by IVUS. IVUS is not always available. Sometimes, all of the wires pass only through “intimal” space in the IVUS examination. These terms should be defined only by the context of the procedures, not by IVUS findings.

Novel Understanding and Definition of CART In retrograde approach, we can manipulate our antegrade and retrograde wires more precisely, because one works as a landmark of the other. CART: Controlled Antegrade and Retrograde wire Tracking

The Most Important Factor to Predict the Results of Retrograde Approach Once dilatation devices (Corsair, conventional micro- catheter or OTW balloon) are delivered into the distal lumen of CTO and CTO body is dilated, we can expect high success rate of wire crossing either in antegrade or retrograde.

My Proposals to Classify Retrograde Procedures 1) Is CTO body dilated or not? What is the definition of dilatation devices? Do you include balloons, Corsair, conventional micro-catheters, or knuckle wires? 2) Which is the direction of wire crossing through CTO body? Antegrade or retrograde?

My Proposals to Classify Retrograde Procedures Direction of Wire Crossing: Retrograde Antegrade Dilatation of CTO Body: (+) Dilatation of CTO Body: (-)

My Proposals to Classify Retrograde Procedures Direction of Wire Crossing: Retrograde Antegrade Dilatation of CTO Body: (+) Reverse CART CART Dilatation of CTO Body: (-) Retrograde Wire Crossing Kissing Wire

Cerulean Tower Tokyu Hotel TOPIC 2011 2011 July 7 (Thu) – July 9 (Sat) Cerulean Tower Tokyu Hotel Tokyo, JAPAN