当前治疗CTO的逆向疗法.ppt

,書式設定,書式設定,第 2,第 3,第 4,第 5,*,Saiseikai,Yokohama-City,Eastern,Hospital,Saiseikai,Yokohama-City,Eastern,Hospital,書式設定,書式設定,第 2,第 3,第 4,第 5,*,Current strategy of,retrograde wire for CTO,Toshiya Muramatsu MD,Division of Cardiology,Saiseikai Yokohama-City Eastern Hospital,Strategic 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,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 Characteristics,J-CTOConquest,N=451,N=337,Procedural Success,90.0%,89.8%,90.5%,（,initial success,87.9%),88.8%,Conquest trial,All cause death0.4%,(causes:sepsis(n=1),pneumonia/ARDS(n=1),Cardiac death0%,Myocardial infarction4.4%,Q wave MI 0.2%,non Q wave MI(CPK 3 times)4.2%,Stent thrombosis 0%,Stroke0%,In-hospital outcomes,N=451,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,Retrograde Wire,Technique,Guidewire cross from CTO distal site,through collaterals channels supplied,from contrallateral vessel.,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,GW Structure,X-treme,Fielder FC,Fielder,16cm Radio-opaque spring coil,0.009”,0.014”,PTFE Coating,Stainless 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,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.,Retrograde Approach for LAD CTO,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,CART,tecqnique,Pseudo,lumen,True,lumen,Retrograde dilatation of the pseudo lumen,Antegrade puncture,CART,tecqnique for LAD CTO,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,Reverse CART,tecqnique,Pseudo,lumen,True,lumen,Antegrade dilatation of the pseudo lumen,Retrograde puncture,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,Donor vessel dissection,Donor vessel dissection,st,PCI for,LAD,2,nd,PCI-Riverse CART,2,nd,PCI-Riverse CART,Number of CTO lesion,Success rate and retrograde approach for CTO,（）,Strategy of retrograde approach for CTO,Complication of retrograde approach for CTO,（）,Conclusion,1.CTO has complicated multivariate structure in terms of pathology.,2.Reading angiogram is most important point,especially forcus to collateral pathway in diagnostic angiogram.,3.Collateral channel is important not only suppling diatal part of CTO vessel,but also using retrograde approach.,4.Retrograde approach is useful in the case of failed penetration of first CTO guidewire.,5.In future,the possibility of long term opening of CTO will be increased by the emergence of DES,and the further improvement of an initial success will be considered to be a future treatment point.,