当前治疗cto的逆向疗法

Saiseikai Yokohama-City Eastern Hospital Current strategy of retrograde wire for CTO Toshiya Muramatsu MD Division of Cardiology, Saiseikai Yokohama-City Eastern Hospital Saiseikai Yokohama-City Eastern Hospital Strategic ChangesStrategic Changes Retrograde approach 25.1% Seesaw wiring 33.2% GW 4.0 2.4 (max 10) Total 46.4 % Seesaw wiring 43.1% Conquest trial N=116 July, 2003 - March, 2004 J-CTO N=378 April, 2006 - December, 2007 2 years later Saiseikai Yokohama-City Eastern Hospital Approach site (Overall) femoral 80.8%97.4% radial5.1%1.8% brachial 14.2 %0.9% Single site puncture35.4%49.5% Dual site puncture64.6%50.5% GC size 6.9 0.5 Fr7.1 Fr GC size (contralateral) 6.0 1.0 Fr Contrast amount (cc)312 155365 146 Fluoro scopic time (min)52.9 37.850.9 35.7 Total procedural time (min)123.3 65.7 Emergent procedure1.8% Basic Procedural CharacteristicsBasic Procedural Characteristics J-CTOConquestN= 451 Saiseikai Yokohama-City Eastern Hospital N=337 Procedural SuccessProcedural Success 90.0 % 89.8 % 90.5% （initial success 87.9%) 88.8% Conquest trial Saiseikai Yokohama-City Eastern Hospital 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 3 times)4.2% Stent thrombosis 0% Stroke0% In-hospital outcomes N=451 Saiseikai Yokohama-City Eastern Hospital Perforation4.4% (18/408) tanponade0.5%(2/408) Treatment balloon compression2.7% (11/408) 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 Saiseikai Yokohama-City Eastern Hospital Retrograde Wire Technique Guidewire cross from CTO distal site through collaterals channels supplied from contrallateral vessel. Saiseikai Yokohama-City Eastern Hospital Indication of Retrograde Approach lFailed Antegrade Approach lHopeless Antegrade Approach Unknown Entry Point Long CTO(40mm) Heavy Calcium RCA Bent Point CTO Ante GW into Subintimal Space lGood Collaterals Straight, Big, Visible Saiseikai Yokohama-City Eastern Hospital Systems of retrograde technique Retrograde guiding catheter short GC(85-90cm), 7 or 8F, good back-up Retrograde guidewire floppy type GW( fielder, whisper, runthrough etc) Retrograde balloon long and small balloon(150cm,1.25mm), 23atm Saiseikai Yokohama-City Eastern Hospital GW Structure X-treme Fielder FC Fielder 16cm Radio-opaque spring coil 0.009” 0.014” PTFE CoatingStainless 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 Coating Stainless Steel Core 3cm 1cm Saiseikai Yokohama-City Eastern Hospital Retro GW Structure Fielder FC Fielder X-treme Standrad type wire using retrograde Good support in the channel Straightened the collateral channel Small guidewire tip Approach for thinner collateral channel Less support Careful manipulate making dissection Saiseikai Yokohama-City Eastern Hospital My strategy of Retrograde Technique Good support F Guiding Catheter Straight collateral is good root for navigate GW If possible, GW introduce to true lumen retrogradly If impossible、change to CART technique Sometimes,Reverse CART is useful Septal dilatation is not always necessary Ryujinn OTW is good balloon for septal dilatation Careful to contrallateral guiding catheter wedge, thrombus,ischemia. Saiseikai Yokohama-City Eastern Hospital Benefit and Risk of Collateral way Straight Risk of perforation Risk of Tamponade Visibility Length Septal （） Small Small FairGood Moderate Epicardial （） Big Big Good Long Saiseikai Yokohama-City Eastern Hospital Retrograde Approach for LAD CTO Saiseikai Yokohama-City Eastern Hospital 1.Retrograde GW crossing through collateral channel 2.Retro GW enter into subintima space from distal fibrous cap 3.Antegrade GW also enter in the subintima space from proximal site 4. Retro balloon deliver into subintima sapce and dilate 5.Dilating subintima space makes a channel connection between ante and retro GW 6. Ante GW cross through subintimal to true distal lumen CART technique Saiseikai Yokohama-City Eastern Hospital CART technique Saiseikai Yokohama-City Eastern Hospital CART tecqnique Pseudo lumen True lumen Retrograde dilatation of the pseudo lumen Antegrade puncture Saiseikai Yokohama-City Eastern Hospital CART tecqnique for LAD CTO Saiseikai Yokohama-City Eastern Hospital 1.Retrograde GW crossing through collateral channel 2.Retro GW enter into subintima space from distal fibrous cap 3.Antegrade GW also enter in the subintima space from proximal site 4. Antegrade balloon deliver into subintima sapce and dilate 5.Dilating subintima space makes a channel connection between ante and retro GW 6. Retro GW cross through subintimal to true proximal lumen Reverse CART technique Saiseikai Yokohama-City Eastern Hospital Reverse CART tecqnique Pseudo lumen True lumen Antegrade dilatation of the pseudo lumen Retrograde puncture Saiseikai Yokohama-City Eastern Hospital Easy insert balloon from ante CTO site No need of retro balloon through the collateral channel to CTO vessel no chance of complication related collateral - dissection, spasm, perforation- exhaust time during balloon crossing collateral Possible using IVUS Anchoring retro GW by ante ballooning anchor balloon makes a easy crossing microcatheter Ballooning into big vessel of reverse CART means safer than that in smaller vessel of retro ballooning Benefit of Reverse CART technique Saiseikai Yokohama-City Eastern Hospital Complication Donor artery ischmia, spasm or thrombosis Channel dissection Channel rupture Entrapment of retrograde guidewire Guidewire, balloon kink through collateral channel Saiseikai Yokohama-City Eastern Hospital Donor vessel dissection Saiseikai Yokohama-City Eastern Hospital Donor vessel dissection Saiseikai Yokohama-City Eastern Hospital st PCI for LAD Saiseikai Yokohama-City Eastern Hospital st PCI for LAD Saiseikai Yokohama-City Eastern Hospital 2nd PCI-Riverse CART Saiseikai Yokohama-City Eastern Hospital 2nd PCI-Riverse CART Saiseikai Yokohama-City Eastern Hospital LMT thrombus during Retro Saiseikai Yokohama-City Eastern Hospital Number of CTO lesion Saiseikai Yokohama-City Eastern Hospital Success rate and retrograde approach for CTO （） Saiseikai Yokohama-City Eastern Hospital Strategy of retrograde approach fo