the role of imaging to assist cto-pci -...

The role of imaging

to assist CTO-PCI

Gerald S. Werner, MD PhD FESC FACC FSCAI

Medizinische Klinik I

Klinikum Darmstadt GmbH

Imaging for CTO PCI

• Planning before the procedure

• Plaque composition

• Primary choice of strategy

• Analysis of problems with wire advancement

• Guidance in the cath lab

• Visualization of the wire pathway

• Optimization of viewing angles

20 years Post CABG: Ostial RCA CTO

What is the best strategy ?

Retrograde options are challenging

Moderate calcification -> medium-strengh wire

Occluded RCA: Value of MSCT

CTO

CT-scan shows details of the occluded segment

Reference-image“ from CT serves as

navigation support for the cardiologist

Segmentation Intra-op Planning Registration CT/C-Arm Side by side Guidance

The reference gives certainty for the wire advancement

without any other landmark

… and supports the successful recanalization of the

CTO in this case

An example from 2014 (Riga CTO Day)

An example from 2014 (Riga CTO Day)

An example from 2014 (Riga CTO Day)

MDCT analysis of plaque composition

Choi JH et al. Circulation Journal 2011; 75: 366-75 from Seoul, Korea

186 pats with MDCT, 77% success

Plaque density increases with

duration of CTO

Higher HU in failed PCI for CTO

Imaging for CTO PCI

• Planning before the procedure

• Plaque composition

• Primary choice of strategy

• Analysis of problems with wire advancement

• Guidance in the cath lab

• Visualization of the wire pathway

• Optimization of viewing angles

H IM AX IN NC Andreas Meyer

CT Segmentation of coronaries

H IM AX IN NC Andreas Meyer

Angio-CT co-registration

H IM AX IN NC Andreas Meyer

Planning based on co-registered CT

Crossectional view

Longitudinal view

H IM AX IN NC Andreas Meyer

Reference-image from CT follows all movements of C-arm and table

Segmentation Intra-op Planning Registration CT/C-Arm Side by side Guidance

Colouring of centerline indicates foreshortening in relationship to C-arm position

H IM AX IN NC Andreas Meyer

CT-reference serves as navigation support

H IM AX IN NC Andreas Meyer

Successful recanalization of the CTO

Set up in the cath lab

IVUS

MSCT

INTEGRATE

Number of MSCTs for CTO-PCI in my institution

0

50

100

150

200

250

300

2009 2010 2011 2012 2013 2014

MSCT

No MSCT

• Main indication for preprocedural MSCT

• Long ambiguous CTO of the RCA

• Poor visualization of an occluded vessel via

collaterals

• Previously failed procedure

LAD CTO: Where is the proximal cap ?

LAD CTO: Where is the proximal cap ?

LAD CTO: Where is the proximal cap ?

Pullback from distal vessel…

LAD CTO: Where is the proximal cap ?

• An occluded vessel

ostium is a solid structure

• There is a considerable

step-up in vessel size

LAD CTO: Where is the proximal cap ?

LAD CTO: antegrade wire for Rx CART

LAD CTO: Where is the proximal cap ?

IVUS in CTOs

• IVUS in the antegrade approach

• Identify the proximal cap

• Verify true lumen entry

• Try to guide reentry into true lumen

• Verify true lumen position after reentry

• IVUS in the retrograde approach

• Identify issues with hampered retrograde wire

• IVUS guided reverse CART

• Mandatory when approaching left main

• IVUS to optimize stenting in diffusely diseased CTOs

• What is the true vessel size

• How extensive should we cover the vessel by stents

• Can we leave a bifurcation or should we treat it

IVUS in CTOs

• IVUS in the antegrade approach

• Identify the proximal cap

• Verify true lumen entry

• Try to guide reentry into true lumen

• Verify true lumen position after reentry

• IVUS in the retrograde approach

• Identify issues with hampered retrograde wire

• IVUS guided reverse CART

• Mandatory when approaching left main

• IVUS to optimize stenting in diffusely diseased CTOs

• What is the true vessel size

• How extensive should we cover the vessel by stents

• Can we leave a bifurcation or should we treat it

RCA CTO: Strategic options

• Retrograde access

possible

• How likely is it to

pass the retrograde

wire all the way up?

• Antegrade wire

position required

• Antegrade wire

• No entry

• IVUS analysis to inquire

the proximal cap

RCA CTO: Strategic options

Puncture of the cap with Gaia 2

Then via Finecross wire downgraded

Stent placement, the real challenge

Bifurcation is covered with single stent

Complex long RCA CTO

Intramural hematoma and collapsed true lumen

Successful puncture into true lumen

Complex long RCA CTO

IVUS in CTOs

• IVUS in the antegrade approach

• Identify the proximal cap

• Verify true lumen entry

• Try to guide reentry into true lumen

• Verify true lumen position after reentry

• IVUS in the retrograde approach

• Identify issues with hampered retrograde wire

• IVUS guided reverse CART

• Mandatory when approaching left main

• IVUS to optimize stenting in diffusely diseased CTOs

• What is the true vessel size

• How extensive should we cover the vessel by stents

• Can we leave a bifurcation or should we treat it

Date of download:

1/18/2014

Copyright © The American College of Cardiology.

All rights reserved.

From: Fundamental Wire Technique and Current Standard Strategy of Percutaneous Intervention for Chronic

Total Occlusion With Histopathological Insights

J Am Coll Cardiol Intv. 2011;4(9):941-951. doi:10.1016/j.jcin.2011.06.011

Principle of Retrograde Subintimal Tracking

Antegrade subintimal tracking (dotted line) and retrograde subintimal tracking (solid line). Even though the angiogram shows that

the 2 wires are separated (antegrade and retrograde), both wires can be positioned in the same subintimal space. After the

retrograde wire comes into the same lumen with the antegrade wire, crossing into the proximal true lumen with the retrograde wire

is highly promising.

Figure Legend:

Long RCA occlusion in a 51 year old male

Reverse CART, wire does not pass

Romberg

Identify the wire inside the plaque

32577

• Retrograde wire within a

plaque formation

• Antegrade IVUS subintimal

Identify the wire inside the plaque

32577

• Retrograde wire reaching

the plane of the antegrade

wire/IVUS position

• Antegrade IVUS subintimal

Identify the wire inside the plaque

32577

• Retrograde wire reaching

the plane of the antegrade

wire/IVUS position

• Antegrade IVUS subintimal

Identify the wire inside the plaque

32577

• Antegrade IVUS intraluminal

• Retrograde wire exiting again

into massive proximal plaque

Proximal plaque needs to be expanded…

Long RCA occlusion in a 51 year old male

IVUS in CTOs

• IVUS in the antegrade approach

• Identify the proximal cap

• Verify true lumen entry

• Try to guide reentry into true lumen

• Verify true lumen position after reentry

• IVUS in the retrograde approach

• Identify issues with hampered retrograde wire

• IVUS guided reverse CART

• Mandatory when approaching left main

• IVUS to optimize stenting in diffusely diseased CTOs

• What is the true vessel size

• How extensive should we cover the vessel by stents

• Can we leave a bifurcation or should we treat it

What is the real long-term benefit

• Everyone who uses IVUS knows that we

underestimates the real vessel size despite

experience

• We can optimize stent coverage and

expansion by IVUS

• I am convinced that proper use of IVUS

guidance will be superior to angiography, …

• … but we need to prove it by a RCT

ECC 2014: IVUS diversity in CTOs

0

20

40

60

80

100

120

140

160

180

200

220

240

260

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35

IVUS

No IVUS

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35

IVUS

NO IVUS

Imaging for CTO PCI

• Imaging helps to plan and perform CTO PCI

• No one should perform CTO PCI in complex

lesions without IVUS in the lab

• IVUS image interpretation is not trivila and

requires training and experience

• MSCT is a valuable planning tool in long

lesions with no or little calcium in the course

of the lesion

• In selected cases, coregistration may improve

the procedure

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