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1、Current strategy of retrograde wire for CTO,Toshiya Muramatsu MDDivision of Cardiology, Saiseikai Yokohama-City Eastern Hospital,Strategic Changes,GW 4.0 2.4(max 10),Total 46.4 %,Approach site (Overall)femoral80.8%97.4%radial5.1%1.8%brachial14.2 %0.9%Single site puncture35.4%49.5%Dual site puncture6
2、4.6%50.5%GC size 6.9 0.5 Fr7.1 FrGC size (contralateral)6.0 1.0 FrContrast amount (cc)312 155365 146Fluoro scopic time (min)52.9 37.850.9 35.7Total procedural time (min)123.3 65.7Emergent procedure1.8%,Basic Procedural Characteristics,J-CTOConquest,N= 451,N=337,Procedural Success,90.0 %,89.8 %,90.5%
3、（initial success87.9%),88.8%,Conquest trial,Single wire94.0%277 13343.2 31.5(54.6%)Seesaw82.1%339 15350.2 29.3(20.3 %)Retrograde93.3 %436 203.76.4 45.6(11.9 %) Seesaw + Retrograde66.0 %423 15097.9 9.0(12.7%),N=378,Proc. success (%DS 50%),Contributions of Supplemental Strategies,Procedural Time(min),
4、Contrast(cc),All cause death0.4% (causes: sepsis(n=1), pneumonia/ARDS (n=1) Cardiac death0%Myocardial infarction4.4%Q wave MI 0.2%non Q wave MI (CPK 3 times)4.2%Stent thrombosis 0%Stroke0%,In-hospital outcomes,N=451,Perforation4.4% (18/408)tanponade0.5%(2/408)Treatmentballoon compression2.7% (11/408
5、)drainage0.2% (1/408)coil embolization0.5% (2/408)covered stent0% (0/408)surgery0% (0/408)Emergent PCI0.9% (4/451)Emergent CABG0% (0/451)Blood transfusion2.0% (9/451)Access site surgery0.4% (2/451)GI bleeding0.2% (1/451),Complications,Retrograde Wire Technique,Guidewire cross from CTO distal site th
6、rough collaterals channels supplied from contrallateral vessel.,Indication of Retrograde Approach,Failed Antegrade ApproachHopeless Antegrade Approach Unknown Entry Point Long CTO(40mm) Heavy Calcium RCA Bent Point CTO Ante GW into Subintimal SpaceGood Collaterals Straight, Big, Visible,Systems of r
7、etrograde technique,Retrograde guiding catheter short GC(85-90cm), 7 or 8F, good back-upRetrograde guidewire floppy type GW( fielder, whisper, runthrough etc)Retrograde balloon long and small balloon(150cm,1.25mm), 23atm,GW Structure,X-treme,Fielder FC,Fielder,16cm Radio-opaque spring coil,0.009”,0.
8、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 Coating,12cm Spring Coil,3cm Radio-opaque Coil,0.014”,PTFE Coating,22cm Polymer Sleeve & Hydrophilic Coat
9、ing,Stainless Steel Core,3cm,1cm,Retro GW Structure,Fielder FC,FielderX-treme,Standrad type wire using retrogradeGood support in the channelStraightened the collateral channel,Small guidewire tipApproach for thinner collateral channelLess supportCareful manipulate making dissection,My strategy of Re
10、trograde Technique,Good support F Guiding CatheterStraight collateral is good root for navigate GWIf possible, GW introduce to true lumen retrogradlyIf impossible、change to CART techniqueSometimes,Reverse CART is usefulSeptal dilatation is not always necessaryRyujinn OTW is good balloon for septal d
11、ilatationCareful to contrallateral guiding catheter wedge, thrombus,ischemia.,Benefit and Risk of Collateral way,StraightRisk of perforationRisk of TamponadeVisibilityLength,Septal （）SmallSmallFairGoodModerate,Epicardial（）Big Big GoodLong,Retrograde Approach for LAD CTO,1.Retrograde GW crossing thro
12、ugh collateral channel2.Retro GW enter into subintima space from distal fibrous cap3.Antegrade GW also enter in the subintima space from proximal site4. Retro balloon deliver into subintima sapce and dilate5.Dilating subintima space makes a channel connection between ante and retro GW 6. Ante GW cro
13、ss through subintimal to true distal lumen,CART technique,CART technique,CARTtecqnique,Pseudolumen,Truelumen,Retrograde dilatation of the pseudo lumen,Antegrade puncture,CARTtecqnique for LAD CTO,1.Retrograde GW crossing through collateral channel2.Retro GW enter into subintima space from distal fib
14、rous cap3.Antegrade GW also enter in the subintima space from proximal site4. Antegrade balloon deliver into subintima sapce and dilate5.Dilating subintima space makes a channel connection between ante and retro GW 6. Retro GW cross through subintimal to true proximal lumen,ReverseCART technique,Rev
15、erse CART tecqnique,Pseudolumen,Truelumen,Antegrade dilatation of the pseudo lumen,Retrograde puncture,Easy insert balloon from ante CTO siteNo need of retro balloon through the collateral channel to CTO vessel no chance of complication related collateral - dissection, spasm, perforation- exhaust ti
16、me during balloon crossing collateral Possible using IVUSAnchoring retro GW by ante ballooning anchor balloon makes a easy crossingmicrocatheterBallooning into big vessel of reverse CART means safer than that in smaller vessel of retro ballooning,Benefit of Reverse CART technique,Complication,Donor
17、artery ischmia, spasm or thrombosisChannel dissectionChannel ruptureEntrapment of retrograde guidewireGuidewire, balloon kink through collateral channel,Donor vessel dissection,Donor vessel dissection,stPCI forLAD,stPCI forLAD,2nd PCI-Riverse CART,2nd PCI-Riverse CART,LMT thrombus during Retro,Numbe
18、r of CTO lesion,Success rate and retrograde approach for CTO,（）,Strategy of retrograde approach for CTO,Complication of retrograde approach for CTO,（）,Conclusion,1. CTO has complicated multivariate structure in terms of pathology.2. Reading angiogram is most important point, especially forcus to col
19、lateral pathway in diagnostic angiogram.3. Collateral channel is important not only suppling diatal part of CTO vessel , but also using retrograde 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.,
