The Japanese Art of CTO Treatment
Transcript of The Japanese Art of CTO Treatment
Disclosure
Speaker name:
..................Hiroyoshi Yokoi...............................................................
I have the following potential conflicts of interest to report:
Consulting
Employment in industry
Stockholder of a healthcare company
Owner of a healthcare company
Other(s) Cook, Termo, BSJ, Medotoronic, Abott, Medicon
I do not have any potential conflict of interest
☒
Geographical Scope of EVT Physicians
North America
• 40% VS • 40% IC • 20% IR
Europe
• 30% IC • 50% IR • 20% VS
• 10% IC • 15% IR • 75% VS
• 10% IC • 70% IR • 20% VS
• 30% IC • 35% IR • 35% VS
Asia-Pacific
• 10% IC • 30% IR • 60% VS
• 80% IC • 5% IR • 15% VS
Latin America
• 20% IC • 30% IR • 50% VS
IC; Interventional Cardiologist IR; Interventional Radiologist VS; Vascular Surgeon
• 80% IC • 5% IR • 15% VS
Japanese EVT-CTO wiring techniques developed from PCI
Progress of CTO-EVT in Japan
Factors contributing to progress of CTO EVT
• Antegrade approach
0.014-0.018 stiff and taperd CTO wire technology
Imaging Guided approach (Surface echo, IVUS)
• Retrograde approach
Distal site puncture technique
Trans-collateral approach
Progress of CTO-EVT in Japan
Factors contributing to progress of CTO EVT
• Antegrade approach
0.014-0.018 stiff and taperd CTO wire technology
Imaging Guided approach (Surface echo, IVUS)
• Retrograde approach
Distal site puncture technique
Trans-collateral approach
Which wire is appropriate for CTO ?
0.014 or 0.018 or 0.035
In Japan, 0.014-0.018 inch guidewire is favorable than
0.035-inch guidewire in CTO intervention
BTK/SFA SFA/Iliac SFA/Iliac
How to handle guidewires for CTO lesions?
• There are 3 types of techniques to manipulate the guide wires :
1) Controlled Drilling Technique
2) Penetrating Technique
3) Sliding Technique
• For the usual or tortuous lesions, 1) may be better.
Non tapered tip GW or hydrophilic plastic GW
• For the very hard lesions, 2) may be better
Tapered tip GW with strong penetration power
• For the microchannels present ,3) may be better.
Tapered tip plastic-jacket hydrophilic GW
10
Treasure is a hydrophilic coated 0.014-0.018” PTA guidewire,
which possesses superior torqueability due to its structure
using thick stainless steel wires for the spring coil.
70mm 80mm 0.018 inch
150mm (Pt Coil) Hydrophilic Coating PTFE Coating
12g
High torque performance
Good for controlled drilling
From June 2004
11
Astato is a 0.014-0.018” hydrophilic coated PTA
guidewire, which possesses high penetration power with
its 30g tip load and tapered design down to 0.013”.
0.013inch 0.013inch
30g 150mm (Pt Coil)
Hydrophilic coating
High penetration force
Good for penetration
From August 2006
CTO Wire Escalation Techniques
Hybrid Sliding-Drilling-Penetration
Sliding
(Filder XT, Wizard 3)
↓Not cross
Drilling
(Treasure XS 12)
↓Not cross
Penetrating
(Astato XS 9-12)
Cordis Chevalier series
0.012inch 0.008 inch
Radiopaque 3.5cm
Coil Length 15cm
0.014inch
Tip Load:3G
PTFE Coating Hydrophilic Coating
0.012inch 0.009 inch
Pt Coil (Radiopaque) 12cm
0.014inch
Tip Load:30G
PTFE Coating Hydrophilic Coating
Length:190cm
Length:190cm
ProductDistal Diameter
(inch)
Shaft
Diameter (inch)
Coil Length
(cm)
Radiopaque
(cm)
Tip Load
(gf)Coating
Chevalier14
Tapered 3 .012
(Tapered Tip .008) 0.014 15 3.5 3Hydrophilic / Dis.
PTFE / Prox.
Chevalier14
Tapered 30 .012
(Tapered Tip .009)0.014 12 12 30
Hydrophilic / Dis.
PTFE / Prox.
©2015 ASAHI INTECC CO., LTD.
This document contains confidential or privileged information.
Any distribution, copying or forwarding is strictly prohibited.
AMC-K14095
Mini pre-shape Micro-cone tip
Superior directional control with strong torque transmission and penetration
Torque response
Micro-cone tip Penetration
Shape retention
Tip load 12gf Easily catches the entry point of the occlusion
Easy directional control
Advantages in occluded lesions Balanced support shaft
design
Push transmission
Composite Core
Detailed characteristics
©2015 ASAHI INTECC CO., LTD.
This document contains confidential or privileged information.
Any distribution, copying or forwarding is strictly prohibited.
AMC-K14095
Micro-cone tip Tip load 7.5gf
Deflection and directional control with the balanced penetration force and torque response
Deflection control
Balanced support shaft
design
Composite Core Torque response
Penetration
Push transmission Easily catches the entry point
of the occluded lesion
Easy directional control
Advantages in the occluded lesion
Detailed characteristics
Mini pre-shape Shape retention
Radiopaque 3cm 0.014inch
PTFE Coating Hydrophilic Coating
Length:190cm : SUS core
Tip load 100g
25°1mm pre-shaped
Jupiter MAX product spec.
Length Distal Diameter Shaft
Diameter Coil
Length
Radioparque
Marker
Hydrophilic Coating
Coat Type
Hard15
190cm
0.012” 0.013” 7cm 7cm 8cm Hydrophilic/ PTFE
Hard30 0.013” 0.014” 5cm 5cm 5.5cm
Hard50 0.013” 0.014” 4cm 4cm 5.5cm
PTFE coat Hydrophilic coat
*Naveed Hard15,30,50 was previously sold by FMD as NEXUS series
Naveed 4 Hard 15 / Hard 30 / Hard 50
Variety of heavy weight tip load wires for CTO lesions
Length: 190cm
Rapid Exchange Lumen & OTW Lumen
Dual Lumen Catheter
Rapid Exchange Lumen(0.014inch)
OTW Lumen(0.014inch)
Significance of using Crusade catheter (PCI Case)
1. enable crossing of GW into complex side branch
2. enable re-crossing of GW through stent strut
3. avoid tangling of GW
4. avoid delivery of GW exterior of stent strut
5. attempt crossing of GW into CTO lesion by OTW lumen support
Progress of CTO-EVT in Japan
Factors contributing to progress of CTO EVT
• Antegrade approach
0.014-0.018 stiff and taperd CTO wire technology
Imaging guided approach (Surface echo, IVUS)
• Retrograde approach
Distal site puncture technique
Trans-collateral approach
Guidewire Crossing of CTOs under Ultrasound Guidance
SFA Just CTO 0.014inch GW
by courtesy of Miyamoto
2.9 Fr
(distal shaft)
2.5mm
3.5mm
2.5 Fr
(distal shaft)
20mm
2.4 Fr
(distal shaft)
( (
( (
( ( ( (
Eagle Eye® Platinum ST (Volcano)
Navifocus WR (Terumo)
OptiCross (Boston)
( (
( (
( ( ( ( (
( ( (
( ( ( (
wire preceding
IVUS-guided technique for long SFA CTO
Prox
Mid
Dis
IVUS preceding
wire preceding
wire preceding IVUS preceding
or
( ( ( (
( ( ( ( ( ( ( (
( ( ( (
Intraluminal vs. subintimal
All the effort we do for getting the intraluminal space
using several techniques and devices.
Antegrade approach sometimes fails
Advancing into CTO
lumen
Successful penetration Wiring in CTO body
Progress of CTO-EVT in Japan
Factors contributing to progress of CTO EVT
• Antegrade approach
0.014-0.018 stiff and taperd CTO wire technology
Imaging Guided approach (Surface echo, IVUS)
• Retrograde approach
Distal site puncture technique
Trans-collateral approach
Summery of puncture position
Target artery puncture position depth
Anterior tibial Frontal surface
Dorsal artery Frontal surface
Metatarsal artery Frontal surface
Peroneal artery Frontal deep
Posterior tibial Lateral mild
Lateral Plantar artery Lateral deep
Medial plantar artery Lateral mild
Ipsi = Frontal Contra = Lateral
Trans-collateral / pedal approach Distal site puncture
Various retrograde access technique
Posterotibial Anterotibial Trans-pedal Trans-collateral
After the distal puncture, sheathless technique is mandatory.
by courtesy of Nakama
After the retrograde system set up
Reverse CART
CART
Double balloon
Wire rendezvous
CART: controlled antegrade and retrograde subintimal tracking
3Fr sheath or OTW balloon
3Fr sheath or OTW balloon
The Japanese Art of CTO Treatment
• Antegrade approach
0.014-0.018 stiff and taperd CTO wire technology
Imaging Guided approach (Surface echo, IVUS)
• Retrograde approach
Distal site puncture technique
Trans-collateral approach
Take Home Message
• EVT for CTOs is still technically developing.
• Generally, we have to be very flexible to
change our strategy during EVT.
• We have to be familiar with all of the
techniques, which have been developed.