17:35 TEC PEARLS 2 - Tsuchikane
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Transcript of 17:35 TEC PEARLS 2 - Tsuchikane
GAIA for Retrograde
< Technical Pearls 2 >The Use of Double Lumen CatheterIn CTO-PCIEtsuo Tsuchikane, MD, PhD
Toyohashi Heart Center, Japan
CTO Toyohashi Heart Center
< Technical Pearls 2 >
Etsuo Tsuchikane, MD, PhD
Toyohashi Heart Center, JapanContemporary Reverse CART
CTO Toyohashi Heart Center
Reverse CART
Traditional CART
Retrograde direct crossing
Kissing wire Change in CTO crossing strategyRetrograde Summit Registry 2012
Toyohashi Heart Center
Limitations ofClassic Reverse CARTIn the classic reverse CART, a retrograde wire was advanced first (including attempt at the retrograde direct crossing).Connection was made at the position where bilateral wires was overlapped.
Toyohashi Heart Center
CTO
CTO Toyohashi Heart Center
Retrograde wire
Level 3Too big vessel (6 mm) !3.0 mm balloon
CTO Toyohashi Heart Center
4.5 mm balloon and retrograde Conquest for penetration
CTO Toyohashi Heart Center
Successful reverse CART
CTO Toyohashi Heart Center
Final angiogram
CTO Toyohashi Heart Center
Limitations ofClassic Reverse CARTIn the classic reverse CART, a retrograde wire was advanced first (including attempt at the retrograde direct crossing).Connection was made at the position where bilateral wires was overlapped.Once the retrograde dissection was created by retrograde wiring, the further retrograde direction control became very difficult.In those situations even if we used IVUS guidance, sometimes it took a very long time to make a connection (with many kinds of wire).
Toyohashi Heart Center
CTOGAIA Basic structureASAHI intecc; Japan
Total Length 1900mm
Slip Coat Coating Length 400mm
Coil Length 150mm
0.36mm (0.014inch)
PTFE coat
Various lineups for the different situation or lesionDiameter0.26mm (0.010) - 0.36mm (0.014)Tip load1.7gfDiameter0.28mm (0.011) - 0.36mm (0.014) Tip load3.5gfDiameter0.30mm (0.012) - 0.36mm (0.014) Tip load4.5gfASAHI Gaia FirstASAHI Gaia SecondASAHI Gaia ThirdLong hydrophilic coating that enhance the smooth controllability in micro catheter.First:0.26mm (0.010inch)Second:0.28mm (0.011inch)Third:0.30mm (0.012inch)
CTO Toyohashi Heart Center
Conquest family
Miracle 12
Progress 120
Ultimate 3
Pilot 200
XTA
others
GAIA 1st
GAIA 2nd
Wire used for CTO crossing in both approachesBefore June 2012
After June 2012
Toyohashi Heart Center
Contemporary Reverse CARTwith GAIAGAIA enables the intentional retrograde wire direction control.However once the retrograde dissection is created, the precise control become difficult even if GAIA is used.Before retrograde wiring with GAIA, antegrade preparation should be recommended to facilitate reverse CART.
Toyohashi Heart Center
CTO
RCA CTO
CTO Toyohashi Heart Center
CTO with diffuse narrowing
CTO Toyohashi Heart Center
Antegrade preparation for reverse CART
CTO Toyohashi Heart Center
Antegrade preparation for reverse CART
CTO Toyohashi Heart Center
Retrograde wiring with GAIA 2nd
CTO Toyohashi Heart Center
Final angiogram
CTO Toyohashi Heart Center
RCA CTO
CTO Toyohashi Heart Center
Antegrade tip injection
CTO Toyohashi Heart Center
Antegrade wiring using GAIA 2nd
CTO Toyohashi Heart Center
Antegrade preparation was completed
CTO Toyohashi Heart Center
Retrograde tip injection
CTO Toyohashi Heart Center
Retrograde wiring using GAIA 2nd toward balloon
CTO Toyohashi Heart Center
Retrograde wiring using GAIA 2nd toward balloon
CTO Toyohashi Heart Center
Successful reverse CART
CTO Toyohashi Heart Center
Final angiogram
CTO Toyohashi Heart Center
Contemporary Reverse CARTwith GAIAGAIA enables the intentional retrograde wire direction control.However once the retrograde dissection is created, the precise control become difficult even if GAIA is used.Before retrograde wiring with GAIA, antegrade preparation should be recommended to facilitate reverse CART.
In short CTOs
In long CTOs
Toyohashi Heart Center
CTO
RCA CTO
CTO Toyohashi Heart Center
Failed parallel wiring
CTO Toyohashi Heart Center
Difficult for reverse CART because of short occlusion
CTO Toyohashi Heart Center
Attempt at retrograde direct wire crossing by GAIA 2nd
CTO Toyohashi Heart Center
IVUS examination
CTO Toyohashi Heart Center
IVUS examination
CTO Toyohashi Heart Center
Successful retrograde wire crossing by GAIA 2ndManipulation of GAIA 2nd
CTO Toyohashi Heart Center
Final angiogram
CTO Toyohashi Heart Center
Contemporary Reverse CARTwith GAIAGAIA enables the intentional retrograde wire direction control.However once the retrograde dissection is created, the precise control become difficult even if GAIA is used.Before retrograde wiring with GAIA, antegrade preparation should be recommended to facilitate reverse CART.
In short CTOs, the direct retrograde wire crossing still works well with GAIA w/wo IVUS.In long CTOs
Toyohashi Heart Center
CTO
RCA CTO
CTO Toyohashi Heart Center
Simultaneous injection
CTO Toyohashi Heart Center
Antegrade wiring using GAIA 2nd
CTO Toyohashi Heart Center
Antegrade GAIA looks outside the vessel
CTO Toyohashi Heart Center
Retrograde wiring using Ultimate 3
CTO Toyohashi Heart Center
Successful reverse CART
CTO Toyohashi Heart Center
Type 1 perforation
CTO Toyohashi Heart Center
RCA Otial CTO
CTO Toyohashi Heart Center
Antegrade wiring using GAIA 2nd
CTO Toyohashi Heart Center
Antegrade wiring using GAIA 2nd
CTO Toyohashi Heart Center
Type 1 perforation
CTO Toyohashi Heart Center
Antegrade wiring was stopped and retrograde wiring was started.
CTO Toyohashi Heart Center
Retrograde wiring using SION black
CTO Toyohashi Heart Center
Final angiogram
CTO Toyohashi Heart Center
Contemporary Reverse CARTwith GAIAGAIA enables the intentional retrograde wire direction control.However once the retrograde dissection is created, the precise control become difficult even if GAIA is used.Before retrograde wiring with GAIA, antegrade preparation should be recommended to facilitate reverse CART.
In short CTOs, the direct retrograde wire crossing still works well with GAIA w/wo IVUS.In long CTOs with unknown vessel trajectory, antegrade preparation must be done carefully to avoid vessel perforation.Also the use of other non-tapered (hydrophilic) wires than GAIA should be considered to stay inside the vessel.
Toyohashi Heart Center
CTO
Conquest 9
Conquest 12
Conquest 8-20
others
GAIA 1st
GAIA 2ndWire used for CTO crossingin Retrograde Approach 2013
GAIA 3rd Conquest family: 20%GAIA family: 70%others: 10%
Toyohashi Heart Center
Reverse CART
Traditional CART
Retrograde direct crossing
Kissing wire Change in CTO crossing strategyRetrograde Summit Registry 2012
Retrograde Summit Registry 2013
My Personal Experience 2013
Toyohashi Heart Center
Nuts and Bolts of Reverse CARTIf you have GAIA family, start antegrade preparation before retrograde GAIA wiring in general.
Antegrade ballooning position should be close to distal end of CTO, however be careful antegrade wire position not to make damage beyond the occlusion.
In short CTOs, still the direct retrograde wire crossing may be attempted w/wo IVUS.
In long CTOs, antegrade preparation must be done carefully to avoid vessel perforation by using non-tapered (hydrophilic) wires. Also retrograde GAIA should not be used if a long distance (>20mm) remains to antegrade balloon.
Toyohashi Heart Center
CTO16th CTO Club June 19-20, 2015, Nagoya, Japan
www.cct.gr.jp/ctoclub
Toyohashi Heart Center
CTO57In the next early Summer, we plan toconduct the 8th CTO club in Toyohashi city, Japan. In this course, we can show you around 20 CTO cases in the 2 days.