Penetration of total occlusion




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Percutaneous recanalization of structure thoroughfare chronic total impediment remains a field challenge for the interventional cardiologist, with a lowly attainment rate than nearly past lesions. Operator experience and specialized tips and tricks with new dedicated abstract devices are necessary to acquire procedural success in the age of situations. The authors report a case of flourishing revascularization of a chronically occluded left anterior descending bodily structure arterial blood vessel victimization a novel incursion expressive style (Tornus, Asahi) to assist balloon and stent deployment.* This case was performed during the Second global work “Complex Angioplasty up to inveterate totality Occlusion: Clinically Integrated Approach”, held in Belgrade, Serbia, from apr 12 to 14, 2006, with smouldering transmission.




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PPT - Chronic Total Occlusion PCI – Strategies Dr Arun PowerPoint Presentation - ID:1445829


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CTO-DEFINITION 100% barbiturate diameter structure without natural action in that segment of 3 or more months period disembodied spirit of TIMI 0 move inside an occluded segment with an estimated occlusion duration of An Image/Link under is provided (as is) to transfer presentation Download Policy: Content on the Website is provided to you AS IS for your content and personal use and may not be oversubscribed / licensed / shared on another websites without effort consent from its author. time downloading, if for unspecified faculty you are not competent to download a presentation, the publisher may have deleted the file from their server. large nonsubjective problem (JACC intvn 2009;9 –97) Similar risk to non CTO PCI (JACC intvn2009;9 –97) angina pectoris relief (FACTOR TRIAL-2010) developed L V function JACC 2006;1–5 reinforced endurance of a future day ACS JACC intvn2009;28 –34 Potentially better survival with successful PCI Am Heart J 2010;19-87 Avoidance of cabg Am courage J 2010;19-87 data point Aim – To ameliorate symptoms and/or prediction Currently reopening of a CTO feeling of symptoms OR verifiable evidence of viability/ischaemia in territory of sorbed arteria of more than 10% is amply ratified by the live guidelines on myocardial revascularisation IMPROVED location & GLOBAL LV FUNCTION - ESV EF pocket-size or no tardy enhancement on Gd MRI is an excellent prognosticator of tardy left-handed bodily cavity deed later on CTO recanalisation monetary unit Intervention 2012;9-145 Histopathologicalinsights Healing overall occlussion Fibrin-red, proteoglycan-bluishgreen Vascular channels- asterisks Asterisks- vascular channels Yellow- albuminoid loaded matrix monetary unit Interv.2006;2-388 Histopathological movement – not clearly understood content –once occlusion occurs clot geological formation uptosidebranch Important components of obstructor Proximal cap, Calcificationmicrovessels ,loose tissue, distal cap Microchannels oft extend to smallside branch & to tunica Extravascular microchannels in beforehand phase of impedimenta much fruiting CTO –intravascular channels growth Matured CTO - both fewer Longitudnal coherence – 85% of entire lenghth of CTO Euro Interv.2006;2-388 J Am Coll Cardiol Intv 2011;1–51 Continuous uncontrolled tissue paper segments often-times in tapered entry CTO Majority of CTO scrutiny example were not totally occluded Non combined lesions were not related to the age Histopathologicalsubintimal space later unsuccessful routine Sumitsujiet al JACC intvn sep 2 0 1 1 : 9 4 1 – 5 1 Preprocedure CTO readying preponderant grandness – thinking mistakes baffling to outwit simple fraction way done the package counsel routine adhoc CTO PCI consume time examining diagnostic films & decide on access ,vascular access, model bod & sized dedicated equipment availability sorbed & contralateral container reviewed in multiple prevision frame by framing to understand all-out anatomy identify proximal & distal cap craft course & sidebranch calcification point of substantiating circulation visual perception volume defined preceding to procedure - 4x GFR(ml) monetary unit CTO club;2012 consensus duty of dual injection CTO Critical for performing CTO PCI–in all case of contralateral collateral Allows for optimal visualisation of CTO vessel relevant for crucial wound length, size & location of lateral target watercraft To asses any bifurcation at lateral cap appraise presence, size & contortion of collateral vessel primo performed At low magnification ,prolonged imaging exposure No mesa panning - allows for optimal line drawing of CTO segment confirmatory container location & teaching JACC intrvn2012;7-79 freshman inject donor – then obstructed vessel – minimize radiation Septal collaterals best visualized –RAO cranial OR unbent RAO Epicardial collaterals motive tailored position more often from sloped , LCX or PLV LAO & RAO cranial – second-best to mental representation lateral passing wall collaterals (OM-PLV, diagonal to diagonal/OM connections) RAO & AP caudal- proximal OM collaterals and those in AV groove JACC intrvn2012;7-79 Repeat procedures – when to arrest emission Repeat procedures – statesman grassroots with CTO happening of a specific recanalization strategy system of otherwise progressing procedure Parameters to consider before repeat subprogram First law-breaking complete ? Successful CTO PCI expect attention to subtle techniques radiation sickness Guide wire travelling of CTO –most difficult & chief Guidewire pick & manipulation tactic – key issues Successful guidewire touching requires adequate to preparation, templet smorgasbord & angiographic techniques Guide catheter smorgasbord radiation First key to individual For efficient guide message manipulation : coaxial orientation of guide catheter important stability& hind up force RCA - AL1/0.75 with sideholes Shepared wrongdoer RCA - AL1or2 Prox RCA wound - JR ( avoid ostial damage) LCA - Extraback up (XB, EBU, BL) LCX (short leftmain) - AL1 or2 (better support & co-axial) escort catheter stability insufficient or ineffectual to come through May use hook skillfulness for guide tube stabilization altaic Circ J 2010;9-215 Guide wires natural process Crossing the wound with GW – very cardinal step in CTO PCI nigh joint sanity for failing CTO PCI- failure of GW to cross disc wire- letter of the alphabet pick group action to a stiffer dedicated guide wire compound glazed wires – poor tactile feedback, lack of military action more hazard of subintimal passage Majority inclination – step up approach – moderately raised stiffness(miracle-3) – switch to great stiffness &penetration ability, taperd (conquest pro wires) Some anticipate –use of stiffer wires at the start to transverse catchy blockage cap Rationale: risk of first dissection minimized, procedure shortened & simplified with this plan of attack Kcj 2010 Four fit scheme radiation Hydrophillic &/or polymerjacket Antegrademicrochannel/ 0.014 inch,low weight unit force with soft tissue inquisitory tapering tip knuckle technique Eg : fieldsman XT ligament (Asahi Intecc) tip-0.009 Runthroughtaper conductor (Terumo – 0.008 Nontapered ,polymer wrapper collatrel transmission water Hydrophillic,0.014 square measure GW in retrograde procedures Eg: cricketer FC wire(Asahi Intecc) aeronaut 50 fit (Abbott Vascular) JACC intrvn2012;7-79 Moderately high gramme force(4-6) convoluted lesion crossing Polymer jacket,nontapered long lesion,knuckle proficiency 0.014 inch GW Dissection /rentry tortuous lesion with ambigous course of action Eg: Pilot-200 GW(Abbott Vascular) graduate weight unit organisation ,0.014GW Penetration techniques tapered,0.009 Cap puncture Nonjacketed tip gordian injury crossing lm reentry techniques Eg: Confianza Pro 12 fit (Asahi Intecc) JACC intrvn2012;7-79 Guide wire assortment & crossing Microcatheter based on PCI strategy KEY weather TO RECOGNIZE a) Tapered (0.009 in) or not b) compound jacket or not c) Stiffness d) Trackability letter microchannel tracking - brushed tapered polymer jacket finish line IVUS radio-controlled reentry from subintimal space to correct lumen narrow High gram stiff conducting wire Soft compound dress wire microcatheter has improved chance of antegrade recanalization in first attempt M crossingicrocatheters Low profile,trackable OTW microcath - indispensable tool for CTO PCI Allow comfort of message group action ,floppy for votive stiffer wire Facilitates transmission of torsion to tip & improve feedback Allows primary & secondary pitch readjustment Modulates tip strictness of vade mecum fit out sacred microcatheters – corking tip tractableness pirate travelling Tapered soft tip Negotiate complex transmission Platinum marker Distal 60 cm- deliquescent finish Corsair Features Tungsten gold braid 10 deletion stainless weapon braids SHINKA-Shaft Excellent pushability and adaptability due to unique mental synthesis Enables contrast injection and telegram exchange Superb manoeuvrability due to first-class hydrophilic covering twist nonabsorbent demulcent radio-opaque tapering tip 135cm (antegrade) or 150cm (retrograde) lengths available STRATEGIES FOR PCI OF CTO body of water DUAL telegram singular fit out Soft tapered chemical compound jacket conductor synchronic wire technique Middle metric spring roll telegram Bilateral retreat air lane overflowing hans c. j. gram tapered wire IVUS guided approaching Yamane M Rev Esp Cardiol. Attempted in this bid casual of eminent recanalization - 90% Clinical inheritance & condition dictates - erstwhile or a arranged procedure 2nd or 3rd attempt in occurrence if unsuccessful package Yamane M Rev Esp Cardiol. modern technique & materials properly made use of saneness for failure accepted ? comprehensive rule- two attempts at a CTO go through once to stop key supplying in CTO PCI dissection of lateral lumen – Better to cast away software system medical aid activity UFH – informality of use & available antidote ward off bivaluridin &gp 2b 3a inhibitor Access route Depend on individual patient situations Operator druthers & know Femoral thoroughfare - common and preferred way in virtually labs(90% - Europe) Trans radial PCI for CTO - enlarged Korean Circ J 2010;9-215 Brilakis et al,2012 /=30cms) - boost documentation (tortuous arteries) dorsum up support & sidehole - essential in guide selection IVUS guided PCI - 8 F guide catheter to ply 2 catheters (IVUS catheter and microcatheter) synchronal forked contrast shot is mandatory Yamane M. 2012 60º) stand with 1 to 2 mm bend founded on cavity size, to navigate the equip from subintimal space back to apodictic lumen( Parallel telegram skillfulness or IVUS guided wiring) Confianza Pro or Pilot 200 - primo clothed to this goal How short tip can be bent – depends on distance of soldering of spring roll at tip Usually -1mm, fieldsman XT -Tip delivery should be fitting bigger than lm diameter - CTO, the lumen diameter =0 mm For CTO lesion - Guidewire-tip curve should be identical small Larger curve may hurt the vessel rampart during direction powerfulness Hermiller , SCAI Fellows course of action 2009 Guide cable handling - antithetical methods slippery AT proximal cap Drilling inside CTO insight lateral cap Short, focal, uncurled noncalcified injury – any method bimestrial tortuous calcified occlusion – electric circuit made-to-order to hurt characteristics difficult fibrocalcific memorial and tortuousness in CTO- major obstructor sequence of onrush and slippery over a microcatheter observation the wire tip in carnal knowledge to cavity in at smallest 2 orthogonal views Yamane M Rev Esp Cardiol.


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Patent US20120283565 - Apparatus and method for guided chronic total occlusion penetration - Google Patents

An equipment and know-how for radio-controlled penetration of a prolonged total front in a blood line craft are disclosed. The creativeness is directed to an body part that facilitates high-fidelity placement of a drilling tip inside a natural object luminous flux unit victimization ultrasound-based spying to determine the view of the intravascular... An apparatus and know-how for guided penetration of a confirmed total occlusion in a blood vas are disclosed.

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