1. Featuring CTO Complex-PCI by Trans-radial Approach CTO Case review 5 French TRI CTO of right coronary artery -5 F Launcher guiding Catheter (right Judkins catheter) -Galeo Medium wires Buddy wire technique Early angio Late angio Martial Hamon - 48 years old patient - Recent ACS, dilated on LAD 7 days ago - Excellent LVEF (EF: 75%) - No Q-wave MI - CTO of Right Coronary Artery (RCA) - Planned procedure: RCA desobstruction By TRA using 5 French guiding catheter

2. Featuring CTO Complex-PCI by Trans-radial Approach Background Pathology  Small vascular channels (160 to 230 microns diameter)  Connect with proximal part Non visualized by angiography  Non visualized by angiography  Islands of dense fibrous tissues 1.Early angiogram frequently no entrance visible 2.Late angiogram distal opacification seen Pathology of CTO Lesions FOCUS

3. Featuring CTO Complex-PCI by Trans-radial Approach 1. Functional vs absolute occlusions 2. Duration of occlusion (>3months) 3. Morphology at occlusion point (tapered vs abrupt, bridging coll., side branch) 4. Lesion length Predictors of success : Patient Selection 1.Documented ischemia? 2.Vessel importance? 3.Alternative solutions? 4.Optimal medications? 5.Benefit / risk? Patient : AdvancedPCI Lesion Selection AMI, CABG, death,perforation, tamponade, excessive contrast load and fluoroscopic Potential Complications:

4. Featuring CTO Complex-PCI by Trans-radial Approach 1.5 F provides optimal backup and support (deep cannulation was possible as seen in figures 2 and 3 by gentle clockwise rotation of the guiding catheter, Launcher 5F from Medtronic) 2.Guide wire Galeo M was successful using buddy wire technique (Figure 1, Galeo M wire from Biotronik) 3.Low-profile balloon: 1.25 mm in diameter and 15 mm length from Terumo was used to create the first channel (Figure 2, Riujyn balloon from Terumo) CTO 5 French TRI Buddy wire techniqueLow-profile balloonLong balloon dilation Fig.1Fig.2Fig.3

5. Featuring CTO Complex-PCI by Trans-radial Approach After balloon inflations After implantation of stents CTO 5 French TRI CTO by trans-radial approach and with 5 French guiding catheter Is safe and feasibile in selected cases and with adapted materials

6. Featuring CTO Complex-PCI by Trans-radial Approach 1. Guiding catheters (optimal backup and support) 2. Guide wire support catheter (or over the wire balloon) 3. Guide wire (intermediate and stiffer, tapered and hydrophilic) 4. Interventional devices (low-profile balloons, rotablator, …) 5. Stents and DES (restenosis) 6. IVUS Material Selection Hydrophilic guidewireTapered-tip guidewire Recommendations

7. Featuring CTO Complex-PCI by Trans-radial Approach Double guide wire technique (buddy wire) S ide branch Technichal aspects V asa vasorum Side branch Vasa-vasorum

8. Featuring CTO Complex-PCI by Trans-radial Approach AdvancedPCI The last Frontier  IVUS Guidance (entry site, complex dissection)  Contro-lateral access (dual arterial access sites)  Stiff wires (penetration wire)  Anchorage techniques  Rotablator (calcified lesion)  Meticulous review of angiograms+++ Key points Advanced specific recommendations: