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1、Current strategy of retrograde wire for CTO,Toshiya Muramatsu MD Division of Cardiology, Saiseikai Yokohama-City Eastern Hospital,Strategic Changes,GW 4.0 2.4 (max 10),Total 46.4 %,2 years later,Approach site (Overall) femoral 80.8% 97.4% radial 5.1% 1.8% brachial 14.2 % 0.9% Single site puncture 35
2、.4% 49.5% Dual site puncture 64.6% 50.5% GC size 6.9 0.5 Fr 7.1 Fr GC size (contralateral) 6.0 1.0 Fr Contrast amount (cc) 312 155 365 146 Fluoro scopic time (min) 52.9 37.8 50.9 35.7 Total procedural time (min) 123.3 65.7 Emergent procedure 1.8%,Basic Procedural Characteristics,J-CTO Conquest,N= 45
3、1,N=337,Procedural Success,90.0 %,89.8 %,90.5% （initial success 87.9%),88.8%,Conquest trial,Single wire 94.0% 277 133 43.2 31.5 (54.6%) Seesaw 82.1% 339 153 50.2 29.3 (20.3 %) Retrograde 93.3 % 436 203. 76.4 45.6 (11.9 %) Seesaw + Retrograde66.0 % 423 150 97.9 9.0 (12.7%),N=378,Proc. success (%DS 50
4、%),Contributions of Supplemental Strategies,Procedural Time (min),Contrast (cc),All cause death 0.4% (causes: sepsis(n=1), pneumonia/ARDS (n=1) Cardiac death 0% Myocardial infarction 4.4% Q wave MI 0.2% non Q wave MI (CPK 3 times) 4.2% Stent thrombosis 0% Stroke 0%,In-hospital outcomes,N=451,Perfora
5、tion 4.4% (18/408) tanponade 0.5%(2/408) Treatment balloon compression 2.7% (11/408) drainage 0.2% (1/408) coil embolization 0.5% (2/408) covered stent 0% (0/408) surgery 0% (0/408) Emergent PCI 0.9% (4/451) Emergent CABG 0% (0/451) Blood transfusion 2.0% (9/451) Access site surgery 0.4% (2/451) GI
6、bleeding 0.2% (1/451),Complications,Retrograde Wire Technique,Guidewire cross from CTO distal site through collaterals channels supplied from contrallateral vessel.,Indication of Retrograde Approach,Failed Antegrade Approach Hopeless Antegrade Approach Unknown Entry Point Long CTO(40mm) Heavy Calciu
7、m RCA Bent Point CTO Ante GW into Subintimal Space Good Collaterals Straight, Big, Visible,Systems of retrograde technique,Retrograde guiding catheter short GC(85-90cm), 7 or 8F, good back-up Retrograde guidewire floppy type GW( fielder, whisper, runthrough etc) Retrograde balloon long and small bal
8、loon(150cm,1.25mm), 23atm,GW Structure,X-treme,Fielder FC,Fielder,16cm Radio-opaque spring coil,0.009”,0.014”,PTFE Coating,Stainless Steel Core,16cm Polymer Sleeve & Hydrophilic Coating,11cm Spring Coil,3cm Radio-opaque Coil,0.014”,PTFE Coating,Stainless Steel Core,20cm Polymer Sleeve & Hydrophilic
9、Coating,12cm Spring Coil,3cm Radio-opaque Coil,0.014”,PTFE Coating,22cm Polymer Sleeve & Hydrophilic Coating,Stainless Steel Core,3cm,1cm,Retro GW Structure,Fielder FC,Fielder X-treme,Standrad type wire using retrograde Good support in the channel Straightened the collateral channel,Small guidewire
10、tip Approach for thinner collateral channel Less support Careful manipulate making dissection,My strategy of Retrograde Technique,Good support F Guiding Catheter Straight collateral is good root for navigate GW If possible, GW introduce to true lumen retrogradly If impossible、change to CART techniqu
11、e Sometimes,Reverse CART is useful Septal dilatation is not always necessary Ryujinn OTW is good balloon for septal dilatation Careful to contrallateral guiding catheter wedge, thrombus,ischemia.,Benefit and Risk of Collateral way,Straight Risk of perforation Risk of Tamponade Visibility Length,Sept
12、al （） Small Small FairGood Moderate,Epicardial （） Big Big Good Long,Retrograde Approach for LAD CTO,1.Retrograde GW crossing through collateral channel 2.Retro GW enter into subintima space from distal fibrous cap 3.Antegrade GW also enter in the subintima space from proximal site 4. Retro balloon d
13、eliver into subintima sapce and dilate 5.Dilating subintima space makes a channel connection between ante and retro GW 6. Ante GW cross through subintimal to true distal lumen,CART technique,CART technique,CART tecqnique,Pseudo lumen,True lumen,Retrograde dilatation of the pseudo lumen,Antegrade pun
14、cture,CART tecqnique for LAD CTO,1.Retrograde GW crossing through collateral channel 2.Retro GW enter into subintima space from distal fibrous cap 3.Antegrade GW also enter in the subintima space from proximal site 4. Antegrade balloon deliver into subintima sapce and dilate 5.Dilating subintima spa
15、ce makes a channel connection between ante and retro GW 6. Retro GW cross through subintimal to true proximal lumen,Reverse CART technique,Reverse CART tecqnique,Pseudo lumen,True lumen,Antegrade dilatation of the pseudo lumen,Retrograde puncture,Easy insert balloon from ante CTO site No need of ret
16、ro balloon through the collateral channel to CTO vessel no chance of complication related collateral - dissection, spasm, perforation- exhaust time during balloon crossing collateral Possible using IVUS Anchoring retro GW by ante ballooning anchor balloon makes a easy crossing microcatheter Ballooni
17、ng into big vessel of reverse CART means safer than that in smaller vessel of retro ballooning,Benefit of Reverse CART technique,Complication,Donor artery ischmia, spasm or thrombosis Channel dissection Channel rupture Entrapment of retrograde guidewire Guidewire, balloon kink through collateral cha
18、nnel,Donor vessel dissection,Donor vessel dissection,st PCI for LAD,st PCI for LAD,2nd PCI-Riverse CART,2nd PCI-Riverse CART,LMT thrombus during Retro,Number of CTO lesion,Success rate and retrograde approach for CTO,（）,Strategy of retrograde approach for CTO,Complication of retrograde approach for
19、CTO,（）,Conclusion,1. CTO has complicated multivariate structure in terms of pathology. 2. Reading angiogram is most important point, especially forcus to collateral pathway in diagnostic angiogram. 3. Collateral channel is important not only suppling diatal part of CTO vessel , but also using retrog
20、rade approach. 4. Retrograde approach is useful in the case of failed penetration of first CTO guidewire. 5. In future, the possibility of long term opening of CTO will be increased by the emergence of DES, and the further improvement of an initial success will be considered to be a future treatment point.,