1. Using a deflectable tipped Catheter to treat previously inaccessible lesions Helen Routledge Interventional Fellow Institut Cardiovasculaire Paris Sud SpR Cardiology, University Hospital Birmingham

2. Multiple PCI procedures LCA. Failed PCI to CTO RCA CABG Feb 2006 - RIMA to proximal PDA + SVG to distal RCA May 2006 - Unstable angina 51 year old male Occluded SVG to RCA Patent RIMA to PDA Lesion at ostium of PLA

3. 1 st Attempt at PCI : Guiding Catheter dissection ostium of RIMA Recurrent Angina CCS 3 in Nov 06 Treated for ISR in LCA and DES in proximal RIMA Recurrent angina

4. Intractable Angina Extreme angulation Lesion tortuosity Access 6f RRA, IMA Minimal support

5. BMW (Guidant Corp.) PT2 (Boston Scientific) Whisper (Guidant Corp.) Cross-it (Terumo) Steer-It (Cordis) Impossible to Wire?

6. Re-do bypass grafting Medical therapy Try and get round the bend…..! Venture Catheter Solutions?

7. Venture TM Catheter Over the wire or Monorail low profile, 3.5F catheter Steerable radiopaque tip

8. Venture catheter advanced over Whisper Whisper advanced into PLA

9. Venture Catheter advanced further into PLA Whisper exchanged for BHW (Guidant Corp.)

10. Predilatation, Cypher 2.5 x 18mm Stent, Wire Exchange, Kissing

11. Final result – free of Angina

12. SVG to LCx

13. VentureBHW guidewire Cypher 2.5 x 13mm SVG to LCx

14. Lesion compromising large PLA Venture Catheter deflected towards PLA SVG to PDA

15. Pre-dilated Unable to stent Buddy wire Endeavour

16. Post-dilated, final result

17. Difficult Side Branch Access Before and after Main Branch Stenting

18. 62 year old female - ACS

19. Failure to Wire SB BMW (Boston Scientific) Whisper (Guidant Corp.) Choice PT(Terumo) Venture Monorail + BMW

20. Taxus 3 x 20 12 ATM PTS strategy

21. Taxus 3 x 20 12 ATM

22. Final Kissing, Final Result

23. Failure to Re-wire SB

24. Subocclusion, Occlusion

25. Venture Monorail, kissing

26. Result

27. Side Branch Access - Trifurcation

28. Difficult to wire Septal.. Venture and Whisper

29. Angulation & Tortuous Anatomy Difficult side branches

30. LMS PCI – recrossing to LCx

31. Side Branch Access - Trifurcation MB Stent Pre-dilatation septal

32. Side Branch Access - Trifurcation

33. Tortuosity, double bend, angulation SVG to LAD Venture?

34. Retrograde? Wire advanced to native vessel Angulated and tortuous lesions beyond Grafts 4