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

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

3. 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

4. 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

5. 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

6. LVEF 32%
20 Jun 00 JS

7. JS
LVEF 52%
30 Aug 01

8. 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

9. 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%

10. 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

11. 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

12. 65-yo Male CTO of LAD IVUS ID of distal vessel

13. 65-yo Male CTO of LAD IVUS ID of distal vessel

14. 62-yo Female: CTO of RCA

15. 62-yo Female: CTO of RCA Following initial balloon dilatation

16. 62-yo Female: CTO of RCA
3.8mm
Distal Vessel
4.2mm
Mid Vessel

17. 62-yo Female: CTO of RCA Post Stenting Angiogram
3.5x28mm DES
4.0x28mm DES

18. 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

19. 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

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

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

22. 65-yo Female – CTO of RCA

25. 65-yo Female CTO of RCA

26. 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

27. Extra slides

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

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

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