Essesntials for CTO Recanalization Barry D. Rutherford, MD Ken Huber Chuck Barth Osamu Katoh BDR Masahiko Ochiai

Barry D. Rutherford, MD DISCLOSURES Honoraria Volcano Corporation, Abbott Vascular, Medtronic CardioVascular, Inc.

Essentials for CTO Recanalization Experienced operator (>500 procedures) CTO Day Fortitude and stamina Radiation protection, patient and operator Extensive knowledge of wires, guides, delivery catheters, crossing catheters and balloons Comfort level with IVUS images and wire position Management of complications – perforation, cardiac tamponade Attend CTO courses, mentoring programs

Essentials for CTO Recanalization Assessment of Patient Age Comorbid conditions Duration of occlusion Routine nuclear stress testing – assess degree of ischemia MSCT Scanning Length of occlusion Definition of calcium Evaluation of distal vessel Definition of intra-occlusion angle

Assess Degree of Ischemia in CTO Territory J.S. 48-Year-Old Male 6-Month Post Anterior MI CTO LAD 3.5 & 3.0 S7 Stents

LVEF 32% 20 Jun 00 JS

JS LVEF 52% 30 Aug 01

Strategies for CTO Procedures Study of the Angiogram Morphology of occlusion: blunt vs. tapered Length of the occlusion Calcium in lesion Angle of CTO Distal vessel: size and length Identification of side branches Antegrade or retrograde collaterals Assessment of septal perforators

Antegrade vs. Retrograde Approach for CTO Antegrade Approach Predictors of Success Lesion length < 20 mm Proximal angulation < 45° Tapered vs. blunt entry point None/mild calcification Single lesions No side branch at site of CTO Success Rate > 95%

Essentials for CTO Recanalization: Antegrade Approach Long, 8-Fr femoral sheath (45 cm) Double guides 8-Fr; Judkins type, 90 cm, side holes IVUS to assess point of occlusion Wire sequence Fielder FC or XT Miraclebros 3-6 gm Confianza Pro, Confianza Delivery catheters: FineCross, Corsair Tornus device Anchoring techniques Parallel wires IVUS guidance to re-enter true lumen

IVUS Use in CTO Stenting Identify entry point to proximal cap Development of forward looking IVUS Vessel sizing Stent apposition Avoid longitudinal geographic miss Identification of false lumen (CART Technique) Used in 100% of cases

65-yo Male CTO of LAD IVUS ID of distal vessel

65-yo Male CTO of LAD IVUS ID of distal vessel

62-yo Female: CTO of RCA

62-yo Female: CTO of RCA Following initial balloon dilatation

62-yo Female: CTO of RCA 3.8mm Distal Vessel 4.2mm Mid Vessel

62-yo Female: CTO of RCA Post Stenting Angiogram 3.5x28mm DES 4.0x28mm DES

Antegrade vs. Retrograde Approach for CTO Antegrade Approach Predictors of Failure Lesion length > 20 mm Proximal angulation > 45° Blunt vs. tapered entry point Heavy calcification Multiple lesions Side branch at site of CTO If 3 or more factors present, consider RETROGRADE APPROACH

Essentials for CTO Recanalization: Retrograde Approach Long, 8-Fr femoral sheath (45 cm) Double guides 8-Fr; Judkins type, 90 cm, side holes Learn to cut short guides Septal surfing; Channel dilator (Corsair), Fielder FC Selective injection of retrograde collateral (septal, epicardial) Wire kissing Wire externalization (300cm Fielder, Rotofloppy wire) CART and Reverse CART IVUS guidance for re-entry Anchoring techniques STAR (sub intimal tracking and re-entering) Reverse CART stenting

Antegrade vs. Retrograde Approach for CTO Retrograde approach depends on available collaterals Epicardial Intramyocardial-septal perforators Interatrial Bypass graft

CTO – Retrograde Approach Evaluation of Septal Perforators Katoh Classification Amplitude of collateral Diameter of collateral  2

65-yo Female – CTO of RCA

65-yo Female CTO of RCA

Essentials for CTO Recanalization Conclusion Success depends on: Careful evaluation of pts – symptoms and ischemic burden Detailed review of angiogram Decision on antegrade vs retrograde approach Develop familiarity with – IVUS evaluation, parallel wire technique, channel dilator, anchoring techniques, CART, STAR techniques Should Approach 90% Success Rate

Extra slides

Case 3 57-yo Male CTO of RCA 2-yrs duration

Case 3 57-yo Male CTO of RCA 2-yrs duration

Case 3 57-yo Male CTO of RCA 2-yrs duration