chronic total occlusions

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Slide 1 : CTO MANAGEMENT
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Slide 17 : Pathology of a Total Occlusion and the Strategy Employed
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Slide 35 : Guidewires for Drilling Strategy     - Persuader   - Miracle Bros     - Cross-It
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Slide 37 : Guidewires for Penetrating Strategy     - Cross IT    -  Conquest Pro     Liber 8
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Slide 39 : A) Guidewires for Approaching Micro-channels      Crosswire NT   Whisper / Pilot    - Rinato    -  Shinobe / Shinobe Plus    -  ChoICE PT / ChoICE PT ES    -  PT Graphix    -  PT2
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Slide 44 : Retrograde Technique The logic behind this approach is that the distal fibrous cap of the CTO may be weaker than the proximal fibrous cap, resulting in easier wire crossing.
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Slide 46 : Guidewires for Retrograde Technique     -Fielder/FielderFC    - X -treme    - Whisper    - ChoICE PT2   -  - Runthrough / Runthrough Hypercoat
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Slide 48 : RETROGRADE APPROACH indicated in patients undergoing failed PCI by the antegrade approach
Slide 49 : GUIDING CATHETERS Use of larger size than 7-French guiding catheters is recommended because solid back-up force by guiding catheters is required for antegrade and retrograde crossing of devices over the CTO lesions. extra backup for the left coronary arteries and Amplatz for the right coronary arteries are mainly selected for the retrograde access. Judkins or Voda Left type guiding catheter is also utilized.
Slide 50 : deep engagement of the retrograde guiding catheter into the coronary artery unexpectedly occurs. emphasized that a side-hole at the tip of the guiding catheter is necessary for the retrograde access. During the PCI procedure, sufficient dose of heparin for maintaining ACT > 250 seconds should be systemically administered to prevent thrombus formation.
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Slide 52 : SELECTION OF RETROGRADE ROUTE Even though collateral connections are not visible on usual angiograms, selective injection of contrast medium (˜0.5 ml) and nitrate through a microcatheter is sometimes. The most adequate condition for being the retrograde route is not diameter but minimum tortuosity of the channel.
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Slide 54 : septal branches between left anterior descending artery and right coronary artery are favorable retrograde access for procedural safety. Although guidewire-induced perforation of epicardial arteries may cause cardiac tamponade, the same accident in septal branches resulting in intra-septal hematoma is harmless.
Slide 55 : CROSSING GUIDEWIRE VIA RETROGRADE ROUTE A microcatheter (Finecross®-150 cm, Terumo, Japan; Excelsior®-150 cm, Boston Scientific, USA) is firstly delivered to epicardial donor artery and determined collateral channel according to navigation by a floppy guidewire (Runthrough-NS®, Runthrough-NS Hypercoat®, Terumo, Japan) or a plastic-jacket hydrophilic guidewire (Fielder-FC®, Asahi Intecc, Japan; Whisper®, Abbott, USA; Choice-PT2®, Boston Scientific, USA).
Slide 56 : After delivery of the microcatheter to the collateral channel, a tip of the wire is reshaped and shortly bent in order to cross easily within the collateral segment. The wire and microcatheter are attempted carefully to advance alternatively. When the wire cannot pass through the collateral channel, change of the wire into a new hydrophilic wire (Fielder X-treme®, Asahi Intecc, Japan) with a tip of 0.009 inches is one option. This guidewire is superior to any of the other wires in ability of transit through the collateral channel.
Slide 57 : If the microcatheter does not advance, exchange the wire for a low profile over-the-wire (OTW) balloon catheter (Ryujin Plus®-148 cm, 1.25 mm/10 mm, Terumo, Japan; Lacross®-155 cm, 1.3 mm/10 mm, Goodman, Japan) by use of corresponding extension wire and balloon dilatation for entire collateral channel (e.g., septal branch) at a low pressure (=4 atm) are useful methods After the wire reaches epicardial artery distal to the target CTO lesion, the devices such as the wire, micro-catheter, and OTW-type balloon catheter are inserted as far as possible because movement of heart beating frequently pull them out.
Slide 58 : PENETRATING INTO CTO LESION Retrograde penetration by guidewire from the distal end (fibrous cap) of CTO lesion is firstly attempted under support of the microcatheter or OTW-type balloon catheter. When the distal fibrous cap is too hard to penetrate, pushing reversed hydrophilic wire (e.g., Fielder X-treme®) so-called “knuckle wire technique” often leads it into the CTO lesion and create a subintimal space (Figure 3A). Otherwise, to change the wire into stiffer one gradually (Miracle® 3, 6, 12; Conquest-Pro® 12, Asahi Intecc, Japan) is recommended.
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Slide 60 : During exchange wire through the OTW-type balloon catheter, the balloon should be inflated at a low pressure (1–2 atm) to prevent kinking of the catheter by tortuous collateral channel. Penetrating antegrade wire into the proximal fibrous cap becomes a landmark of advance of the retrograde wire and reduces volume of contrast mediums during the procedure.
Slide 61 : CONTROLLED ANTEGRADE AND RETROGRADE SUBINTIMAL TRACKING (CART) Surmely the retrograde balloon dilatation within the CTO lesion to create suboptimal space enables the antegrade wire to lead into the distal true lumen through the subintimal space.
Slide 62 : After passage of the antegrade wire through the CTO lesion, transition of the procedure retrograde into antegrade is performed. If the antegrade balloon crossing is impossible, penetration and lumen dilatation by a special catheter (Tornas®, Asahi Intecc, Japan) or increasing buck-up support by 5-French straight child-catheter (Heartrail®, Terumo, Japan) is useful.
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Slide 64 : REVERSE CART subintimal space created by the antegrade balloon dilatation in the CTO enables the retrograde wire to guide to the proximal true lumen through the subintimal space This strategy is called “reverse CART technique”. The retrograde wire is inserted as far as possible (e.g., into aorta or the antegrade guiding catheter).
Slide 65 : ADJUNCTIVE STRATEGIES combination of the antegrade and retrograde balloon dilatation within the CTO segment. Two approximated balloons are inflated simultaneously or alternatively, and bidirectional subintimal space is created. Afterwards, the antegrade and/or retrograde wire is penetrated into the opposite subintimal space.
Slide 66 : COMPLICATIONS 1) guidewire-induced perforation of collateral channel resulting in hemopericardium, cardiac tamponade, and intra-septal hematoma, 2) transient ischemia caused by reduced collateral flow, 3) ostial dissection of the collateral-donor coronary artery due to deep engagement of the antegrade guiding catheter, 4) arrhythmia including bradycardia.
Slide 67 : Complications with Guidewire Usage Entrapped Guidewire when guidewire is repeatedly rotated in a single direction while the distal tip is held fixed in a calcified lesion or a CTO, so that torque given at the proximal end is not transmitted to the distal tip. provisional stenting approach for a bifurcation lesion
Slide 68 : three approaches Retrieve the wire percutaneously: If the distal tip of the wire is entrapped in a calcified CTO, the best approach is to try to rotate it in opposite direction.   one may need to advance a small profile balloon to the “attachment” site and use traction coating of the tip may “deglove” and be left behind, which could be “pushed and pasted” against the vessel wall with another stent.
Slide 69 : Leave it alone wire lies within small, chronically occluded coronary vessels or within a distal segment it may left alone
Slide 70 : Surgical removal: In 15-20% of failed percutaneous approach, surgical removal of the entrapped wire is always an option if the wire lies in a hemodynamically significant territory and cannot be removed percutaneously .
Slide 71 : Detachment and Embolization of Guidewire Tip snared using a gooseneck or a loop snare if the fragment lies in proximal, large vessel. use a stent to “push and paste” it to the vessel wall. If the fragment is small and if one is unable to retrieve it, it could be left in-situ.
Slide 72 : Guidewire Fracture one could try to snare it if the fractured fragment lies proximally or use a “double or triple wire technique.”   this technique involves passing 2 or 3 guidewires distal to the fractured segment and rotating all of them in one direction, aiming to entangle the fractured segment of wire. Subsequently all the 2/3 wires are rotated together in one direction to further entangle the fractured wire. Subsequently the whole, entangled collection is carefully extracted into the guiding catheter .
Slide 73 : Guidewire Fracture Another technique is to cross beyond the fractured fragment with a balloon catheter. Once clearly beyond the distal tip of the fractured guidewire, balloon is nominally inflated and the balloon and the fractured guidewire fragment carefully withdrawn into the guiding catheter. Basket type of distal protection devices can also be employed to the same end .
Slide 74 : Accordion Effect A mechanical alteration during maneuvering of stiff guidewires in tortuous coronary arteries frequently induces vessel wall straightening and shortening which alters the mechanical geometry and the curvature of vessel. This leads to appearance of false lesions or coronary pseudo-stenosis in the angiograms
Slide 75 : Accordion Effect inappropriately identified as coronary spasm, dissection or thrombus development Subtraction of the guidewires normally leads to entire resolution of the lesions removal of stiff guidewire Instead a floppy guidewire with a balloon backup, or even better, a micro-catheter may be employed
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