![• Stent sizing : 26.3%
• Stent optimization : 38.0%
• CTO crossing : 35.7%
– Antegrade : 27.9%
– Retrograde : 7.8%
• Imaging for crossing was used more commonly with:
– proximal cap ambiguity (49% versus 26%, p<0.0001)
– side branch at the proximal cap (61% versus 47%, p=0.035),
– blunt/no stump (68% versus 55%, P=0.009)
– longer occlusion length (30 mm [IQR: 22, 50] versus 28 mm [15, 44],
p=0.009)
– Higher JCTO (2.8 vs 2.4, p=0.001) and Progress CTO
( J Am Heart Assoc. 2016;5: e003890 doi: 10.1161/JAHA.116.003890)](https://image.slidesharecdn.com/ivusoctandctophilipdingli-161011134334/85/Philip-Dingli-Javier-Escaned-Intracoronary-imaging-in-CTOs-When-to-use-how-to-use-and-how-to-interpret-the-images-29-320.jpg)
![• Similar success
• Similar MACE (2.7% versus 3.2%, p=0.772)
• Longer procedure
– 192 min [IQR 130, 255] vs 131 min [90, 192], p<0.0001
• Longer fluoroscopy
– 71 min [44, 93] vs 39 min [25, 69], P<0.0001
• Higher mean air kerma radiation dose
– 4.98 Gray [3.11, 6.04] versus 3.42 Gray [2.09, 5.09], P<0.0001
• More median contrast volume
– 310 mL [240, 400] versus 270 mL [200, 360], p=0.004
• Trend toward larger number of stents
– (2.71.3 versus 2.51.2, P=0.07)
( J Am Heart Assoc. 2016;5: e003890 doi: 10.1161/JAHA.116.003890)](https://image.slidesharecdn.com/ivusoctandctophilipdingli-161011134334/85/Philip-Dingli-Javier-Escaned-Intracoronary-imaging-in-CTOs-When-to-use-how-to-use-and-how-to-interpret-the-images-30-320.jpg)
Philip Dingli. Javier Escaned - Intracoronary imaging in CTOs When to use, how to use and how to interpret the images
- 1. Intracoronary imaging in CTOs When to use, how to use and how to interpret the images Philip Dingli MD Javier Escaned MD PhD Hospital Clinico San Carlos Madrid Spain
- 2. Key imaging patterns in using IVUS in CTOs: our terminology at HCSC Planets Kidneys Wires
- 3. How can IVUS aid in CTO´s? A personal list • IVUS-guided ostial CTO wiring • Reverse CART balloon sizing • CART/ADR guidance (no injections) • IVUS-guided re-entry • Assessment of distal vessel • Optimization of stenting • Management of complications • Reduction in contrast use
- 4. How can IVUS aid in CTO´s? A personal list • IVUS-guided ostial CTO wiring • Reverse CART balloon sizing • CART/ADR guidance (no injections) • IVUS-guided re-entry • Assessment of distal vessel • Optimization of stenting • Management of complications • Reduction in contrast use
- 5. Basic Principle 1. Choice of Branch 2. Choice of IVUS 3. Choice of CTO wire IVUS guided wiring
- 7. How can IVUS aid in CTO´s? A personal list • IVUS-guided ostial CTO wiring • Reverse CART balloon sizing • CART/ADR guidance (no injections) • IVUS-guided re-entry • Assessment of distal vessel • Optimization of stenting • Management of complications • Reduction in contrast use
- 8. Reverse CART IVUS imaging in reverse CART
- 9. Balloon sizing with IVUS to maximise subintimal space and to facilitate entry of retrograde wire Ensuring with IVUS that retrograde wire guidewire is within antegrade lumen IVUS imaging in reverse CART
- 10. How can IVUS aid in CTO´s? A personal list • IVUS-guided ostial CTO wiring • Reverse CART balloon sizing • CART/ADR guidance (no injections) • IVUS-guided re-entry • Assessment of distal vessel • Optimization of stenting • Management of complications • Reduction in contrast use
- 12. • Limited room for guidewire maneuvering. • Lack of spatial orientation. • Target is a compressed / collapsed part of the vessel Challenges for IVUS-guided re-entry
- 13. Work in the angiographic angulation showing the largest distance between IVUS probe and working wire. Apply the same principle to contralateral distal vessel opacification Use a wire with high steerability and tip control to re-enter Correlate your IVUS and angiographic images as much as possible Tips for IVUS-guided re-entry
- 14. Correlating IVUS and Angio Images Yamane M / Coronary Stenosis. Imaging, Structure and Physiology / PCR Books
- 15. Tips for IVUS-guided re-entry Yamane M / Coronary Stenosis. Imaging, Structure and Physiology / PCR Books
- 16. Subintimal track Stented subintimal track Identifying subintimal track before and after stenting
- 17. How can IVUS aid in CTO´s? A personal list • IVUS-guided ostial CTO wiring • Reverse CART balloon sizing • CART/ADR guidance (no injections) • IVUS-guided re-entry • Assessment of distal vessel • Optimization of stenting • Management of complications • Reduction in contrast use
- 19. Angio-IVUS co-registration after IVUS-guided wiring
- 21. A B C A B C Assessment of distal vessel
- 23. • Small distal vessel size with negative remodelling predicted by MSCT. • Identification of CTO ostium with MSCT. • Guidance with IVUS. • Favorable CTO characteristics(absence of calcium, no tortuosity). Learning messages from this case
- 24. How can IVUS aid in CTO´s? A personal list • IVUS-guided ostial CTO wiring • Reverse CART balloon sizing • CART/ADR guidance (no injections) • IVUS-guided re-entry • Assessment of distal vessel • Optimization of stenting • Management and prevention of complications • Reduction in contrast use
- 26. Learning messages from this case • Understanding ambiguous angiographic result of CTO PCI • Optimization of stenting in complex PCI
- 27. • Superb visualisation of endoluminal surface and implanted stents • Providing valuable clues on long-term results of CTO PCI. • Limited by the need of contrast administration (avoidance of CIN in CTO patients is a major issue). • Cannot be used by guidance without injections (a problem in CART) A word on OCT in chronic total occlusions
- 28. Use of Intravascular Imaging During Chronic Total O • 619 CTO percutaneous coronary interventions performed between 2012 and 2015 at 7 US centers • Intravascular imaging in 38% • IVUS was used in 67% of retrograde vs 31% of antegrade-only cases (P<0.0001). ( J Am Heart Assoc. 2016;5: e003890 doi: 10.1161/JAHA.116.003890)
- 29. • Stent sizing : 26.3% • Stent optimization : 38.0% • CTO crossing : 35.7% – Antegrade : 27.9% – Retrograde : 7.8% • Imaging for crossing was used more commonly with: – proximal cap ambiguity (49% versus 26%, p<0.0001) – side branch at the proximal cap (61% versus 47%, p=0.035), – blunt/no stump (68% versus 55%, P=0.009) – longer occlusion length (30 mm [IQR: 22, 50] versus 28 mm [15, 44], p=0.009) – Higher JCTO (2.8 vs 2.4, p=0.001) and Progress CTO ( J Am Heart Assoc. 2016;5: e003890 doi: 10.1161/JAHA.116.003890)
- 30. • Similar success • Similar MACE (2.7% versus 3.2%, p=0.772) • Longer procedure – 192 min [IQR 130, 255] vs 131 min [90, 192], p<0.0001 • Longer fluoroscopy – 71 min [44, 93] vs 39 min [25, 69], P<0.0001 • Higher mean air kerma radiation dose – 4.98 Gray [3.11, 6.04] versus 3.42 Gray [2.09, 5.09], P<0.0001 • More median contrast volume – 310 mL [240, 400] versus 270 mL [200, 360], p=0.004 • Trend toward larger number of stents – (2.71.3 versus 2.51.2, P=0.07) ( J Am Heart Assoc. 2016;5: e003890 doi: 10.1161/JAHA.116.003890)
- 31. Kang J et al PLoS One. 2015 Oct 14;10(10):e0140421 126 patients who underwent DES stenting, and post-PCI IVUS of CTO lesions IVUS-based post-PCI MLD (<2.4 mm) and stent expansion ratio (≤70%) values seem to be predictors of ISR in CTO stenting Does IVUS influence outcomes in CTO PCI?
- 32. 402 patients with CTOs randomized to IVUS-guided and angiography-guided groups. Secondarily randomized to ZES or BES. Kim BK et al Circ Cardiovasc Interv. 2015;8:e002592. Does IVUS influence outcomes in CTO PCI?
- 33. Tian et al. EuroIntervention 2015;10:1409-1417 • 230 patients • Recanalised CTO lesion • Randomised to IVUS-guided or the angiography-guided • The use of IVUS for penetration of the true lumen and optimisation of stent expansion was only done in the IVUS- guided group. • Followed with office visits or telephone contact up to 24 months.
- 34. Saito S et al Am J Cardiol 2016;117:727e734) In 8 vessels in whom the stent was implanted into a subintimal space maximum percent neointimal hyperplasia and minimum lumen area was similar in the subintimal segment compared with the adjacent intraplaque segment. Does stenting the subintimal space influence outcomes in CTO PCI?
- 35. Available at the PCR Bookshop at prconline.com Coronary Stenosis: Imaging, Structure and Physiology Additional information on topics covered in this presentation
- 36. Thank You
- 37. ( J Am Heart Assoc. 2016;5: e003890 doi: 10.1161/JAHA.116.003890)
- 38. Intravascular Imaging and Contrast Use
- 39. Mechanical vs Electronic Scans