Philip Dingli. Javier Escaned - Intracoronary imaging in CTOs When to use, how to use and how to...

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

Key imaging patterns in using IVUS in CTOs:our terminology at HCSC

Planets Kidneys Wires

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










Basic Principle

1. Choice of Branch

2. Choice of IVUS

3. Choice of CTO wire

IVUS guided wiring










Reverse

CART

IVUS imaging in reverse CART

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










• Limited room for guidewire maneuvering.

• Lack of spatial orientation.

• Target is a compressed / collapsed part of the vessel

Challenges for IVUS-guided re-entry

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

Correlating IVUS and Angio Images

Yamane M / Coronary Stenosis. Imaging, Structure and Physiology / PCR Books

Tips for IVUS-guided re-entry

Yamane M / Coronary Stenosis. Imaging, Structure and Physiology / PCR Books

Subintimal track Stented subintimal track

Identifying subintimal track before and after stenting










Angio-IVUS co-registration after IVUS-guided wiring

A

B

C

A

B

C

Assessment of distal vessel

• 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








• Management and prevention of complications


Learning messages from this case

• Understanding ambiguous angiographic result of CTO PCI

• Optimization of stenting in complex PCI

• 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

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)

• 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)

• 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)


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?

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?

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 andoptimisation of stent expansionwas only done in the IVUS-guided group.

• Followed with office visits ortelephone contact up to 24months.

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?

Available at the PCR Bookshop at prconline.com

Coronary Stenosis: Imaging, Structure and Physiology

Additional information on topics

covered in this presentation

Thank You


Intravascular Imaging and Contrast Use

Mechanical vs Electronic Scans

Date post:	15-Jan-2017
Category:	Health & Medicine
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Philip Dingli. Javier Escaned - Intracoronary imaging in CTOs When to use, how to use and how to...

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