1. Fu Wai Hospital Jie Qian
IVUS Guided CTO PCI
Fu Wai Hospital
Jie Qian

2. Different IVUS Catheter
Atlantis SR pro2 (Boston)
Eagle Eye (Volcano)

3. IVUS Guided CTO PCI
Wiring Technique
Optimized CTO PCI

4. Antegrade Technique To detect the entry point
Define true or false lumen
To navigate guidewire from false lumen to true lumen

5. Finding entry point
micro catheter
guide wire

6. Case 1

7. Case 1
Lad come in

8. Case 1

9. Define true or false lumen
Three layer structure
Side branch

10. Case 2

11. Case 2

12. Case 2

13. Case 2
Huge hematoma
Wire hematoma
Huge dissection

14. Case 3

15. To navigate guidewire from false lumen to true lumen

16. Case 4
True lumen
Proximal
Re-entry point

17. Retrograde Technique
Tracking the retrograde wire route and verify wire cross into true or false lumen
Reverse CART ( or with stenting), assess proximal vessel size and decide balloon size

18. Case 5

19. Case 5

20. Case 5
Wire in plaque
Wire Out
Retrograde wire

21. Case 5

22. Case 6

23. Case 6

24. Case 6

25. Case 6
Retrograde wire
True lumen

26. Case 6
Hematoma

27. Case 6

28. IVUS Guided CTO PCI
Wiring Technique
Optimized CTO PCI

29. Comparison of Qualitative Data
Ante group (n=23)
Retro group (n=25) 70 60
p=0.50 50
p=0.02 40 11
(44%)
Incidence (%) 10
(40%) 30
p=0.47 6
(26%) 20 6
(24%)
p>0.99
p=0.49 10 3
(13%) 3
(12%) 2
(9%) 2
(9%)
(0%) 2
(8%)
Subintimal
Intramural
Extramural
IVUS-detected
Angiographic
wiring
coronary
coronary
coronary
extravazation
hematoma
hematoma
perforation
Tsujita JACC Interv 2009

30. Stent

31. LAD Plaque Distribution

32. Field of View 5 mm radius 5 mm forward 5 mm forward 1 mm
5 mm to the side
“Tick marks” are 1 mm in cross-sectional plane for easy diameter sizing
This artery measures 9 mm
Investigational Device, not for human use

33. FL.IVUS with RF Tunneling
FL.IVUS with RF Tunneling designed to provide:
CTO Visualization
IVUS imaging will show proximal CTO cap and vessel borders and position of catheter within lesion
Steering
Rotating the tip of the catheter will direct the RF electrode to desired target
Angled RF beam will allow operator to steer away from vessel walls
Lesion penetration
RF waves will ablate tissue allowing tunneling through lesion
Investigational Device, not for human use

34. Example of View
Investigational Device, not for human use

35. Summary（1）
With suitable side branch, IVUS-guided wiring is helpful to find entry point in no stump CTO lesions.
Define true or false lumen can help to decide stenting or not. It also can help to find true and false lumen crossover point, navigate wire from false to true lumen.
In retrograde technique, IVUS is a very helpful tool especially in Retrograde Wire Cross and Reverse CART (or stenting).
To get successful result in CTO-PCI, we should be familiar with IVUS imaging of CTO and use it with proper way.

36. Summary （2）
CTO procedure (especially retrograde approach) cause perivascular trauma which can be detected by IVUS, though angiographically silent.
Distal coronary artery spares plaque accumulation and IVUS can help to decide the stent landing area.

37. THANKS!

38. Case 7

39. Reverse CART with Stenting39

40. IVUS findings Perivascular Trauma
Perivascular Blood Speckle
New Layer Formation
Perivascular Hematoma

41. Plaque Distribution LAD RCA n=75 Average Plaque Burden
(%)
0.2
0.25
0.3
0.35
0.4
0.45
0.5 10 20 30 40 50 60 70 80
LAD
n=75
Average Plaque Burden
(mm)
Distance from Ostium
(%)
0.2
0.25
0.3
0.35
0.4
0.45
0.5 10 20 30 40 50 60 70 80 90
100
RCA
n=61
Average Plaque Burden
(mm)
Distance from Ostium