1. 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

2. 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.,

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

4. Interventional Definition of Intimal and Sub-intimal Spaces

5. 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

6. VH Analysis of CTO
proximal
reference
distal
reference

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

8. Progression of CTO
Srivatsa S. et at. JACC Vol . 29, No :

9. Histopathologic Data A tapered and short CTO is feasible for PCI
Katsuragawa M. et at. JACC Vol . 21, No :

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

11. Conquest Pro in the Sub-intimal Space

12. Compression of the Distal True Lumen by the Hematoma

13. IVUS Examination from the Sub-intimal Space

14. Intimal and Subintimal Space due to Histopathologic Examination4 3 2 1
True lumen 1 2
Intima 3
Subintima 4
Extra coronary 4 3 2
Courtesy of Dr S Sumitsuji

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

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

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

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

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

23. calcification and tortuosity inside the CTO

25. Antegrade “Loose Tissue” Tracking

26. Antegrade Intentional Intimal Tracking CTO without Any Loose Tissue

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

28. Terminology in Retrograde Approach

29. 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.

30. 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

31. 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.

32. 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?

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

34. 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

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