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Crossing BTK lesions
- BTK Techniques revisited-
Osamu Iida, MD, FACC
Kansai Rosai Hospital
Amagasaki, Hyogo, Japan
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Disclosure
Speaker name: Osamu Iida, MD
..................................................................................................
I have the following potential conflicts of interest to report:
Consulting
Employment in industry
Stockholder of a healthcare company
Owner of a healthcare company
I do not have any potential conflict of interestX
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Complex BTK-lesion frequency
(Long lesion and CTO in OLIVE registry)
CTO LL>15cm
64%75%
Iida O, et al. Circ Cardiovasc Interv. 2013;6:68-76.
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CTO Steps in BTK lesions
Wire cross
Devise cross
Gain the lumen
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Wire crossAntegrade
- Intraluminal, Sub intimal- IVUS guide, Echo guide
Retrograde- Distal puncture- Trans collateral, Trans pedal
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Case: trans-collateral approach (0.014 wire technique for PTA)
BK-pre BTA-pre
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Case: trans-collateral approach (0.014 wire technique [Regalia, Asahi] for PTA)
CTO with channel site➡intraluminal approach
Complete occlusion ➡intraluminal approach
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Case: trans-collateral approach (0.014 wire [Regalia, Asahi] technique for PTA)
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Case: trans-collateral approach (0.014 wire [Regalia, Asahi] technique for PTA)
BK-pre BK-post
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Case: trans-tibial 2way approach (0.035 knuckle wire technique [Terumo, Radifocus stiff wire])
ADL: ambulatoryDM, HDHeart: post CABG EF 35%
BT: 38.1゜CW3I2FI3: high riskWBC: 28000/mm3
CRP: 37mg/dLAlb: 2.6g/dL➡super high risk for major amputation
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System
Approach:
Antegrade ipsilateral femoral
Guiding Sheath:
5Fr Destination (Terumo)
Guide Wire:
Radifocus 0.035, J-type (Terumo), Regalia 0.014 (ASAHI)
Back-up Catheter:
CXI ST 4.0Fr, 90cm (COOK)
➡Intentional subintimal approach with .035 J tip Terumo wire
Case: trans-tibial 2way approach (0.035 knuckle wire technique for ATA-CTO with severe calc)
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System
Approach:
Antegrade ipsilateral femoral
Guiding Sheath:
5Fr Destination (Terumo)
Guide Wire:
Radifocus 0.035, J-type (Terumo), Regalia 0.014 (ASAHI)
Back-up Catheter:
CXI ST 4.0Fr, 90cm (COOK)
➡Bidirectional 2-way Tracking
Case: trans-tibial 2way approach (0.035 knuckle wire technique for ATA-CTO with severe calc)
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System
Approach:
Antegrade ipsilateral femoralRetrograde tibial
Guiding Sheath:5Fr Destination (Terumo)4Fr 10cm sheath (Terumo)
Guide Wire:Radifocus 0.035, J-type (Terumo), Regalia 0.014 (ASAHI)
Angioplasty:3.0mm*300mm (BARD)
Case: trans-tibial 2way approach (0.035 knuckle wire technique for ATA-CTO with severe calc)
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The most reliable technique in BTK is “Step by step by knuckle wire technique”
Below-the-knee CTO0.035 knuckle wire
Below-the-ankle CTO0.014 knuckle wire
Final recanalization0.014 3g Gladius wire
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CTO Steps in KRCVC
Wire cross
Devise cross
Gain the lumen
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Case: Guide extension catheter(Revascularization for plantar artery)
Successful recanalization supported by guide extension catheterGuide Extension Catheter (Guidezilla, Boston Scientific), Jade(NEICH®) 2.0*150mm
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CTO Steps in KRCVC
Wire cross
Devise cross
Gain the lumen
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Case: Pierce technique (18G needle cracking for sever calcification)
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BK-pre BTA-pre
Super Calc BTK Pressure-Oriented Balloon Angioplasty (30atm!)
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BK BTA
Vessel prep: SHIDEN HP
3.0*150mm with 30atm (Kaneka, Japan)
Post dilatationDistal: 3.0*300mm (Cordis)Proximal: 3.5-4.0mm*210mm (Medtronic)
Super Calc BTK Pressure-Oriented Balloon Angioplasty (30atm!)
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BK-post BTA-post
Super Calc BTK Pressure-Oriented Balloon Angioplasty (30atm!)
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(A)
(D)
(C)
(B)
(B)
(C)
(D)
Major Axis / Minor Axis1.95/1.77mm
EEM Area2.72
Major Axis / Minor Axis2.55/2.36mm
EEM Area4.75
Major Axis / Minor Axis2.45/2.26mm
EEM Area4.36
Major Axis / Minor Axis2.12/1.99mm
EEM Area3.31
(A)
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Key concept for recanalization of infrapop-CTO with severe calcification
-My style-
1. Bi-directional 2 way approach *tibial or dorsalis retrograde> toranscollateral, transpedal
2. Knuckle wire technique*Less procedural time*Less number of wire use*Cost effectiveness
3. Super NC balloon for prep*Pressure-assisted Plain Angioplasty*30atm is good enough for vessel prep
4. IVUS evaluation*Vessel diameter is larger than you expect by assessing angiography (+0.5mm)*Better inflow can be acquired
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Crossing BTK lesions
- BTK Techniques revisited-
Osamu Iida, MD, FACC
Kansai Rosai Hospital
Amagasaki, Hyogo, Japan