Introduction: Recent data has shown that successful percutaneous recanalization of CTO’s result in improved survival as well as enhanced LV function, reduction in anginas, improved exercise tolerance. However, because of the procedural complexity of angioplasties in CTO’s, it still represents the most common reason for referral to CABG, or for choosing medical treatment. Over the past few years tremendous improvement in PCI equipment, materials & technique specially by the Japanese have allowed us to tackle success in CTO cases.

Histopathology of CTO : CTO consists of lipids, smooth muscles cells, loose or dense fiber tissues (collagen), Neovasular Micro channels. 2) CTO consists of proximal & distal fibrous cap surrounding a softer core of organized thrombus & lipids (body of CTO). 3) The proximal fibrous cap is thicker & harder than the distal fibrous cap which is typically convex shaped when seen from the proximal side, hence difficult to puncture at times and may need the retrograde approach.

Practical tips and tricks for CTO cases : 1) Always 7F Sheath in both groins. 2) Guide selection & support is very important for LCA, 7F XB Guide and for RCA 7F JR4 or AL1.   3) Use minimum dyes, minimum cine pictures, inject dye slowly & gently in small quantity. Avoid forceful dye injection.  

Practical tips and tricks for CTO cases : 4) Traditional method for CTO was to use 6F sheath in groin, start with BMW wire and change over to CTO wires like Cross-it, Miracle & Conquest wires with CTO Balloon support. 1.25/1.5 by 9mm CTO Balloons and go mm by mm to cross CTO.    

In the present cases I have used the Japanese method a novel easy successful technique. Japanese techniques, tips and tricks for CTO cases :

Japanese techniques, tips and tricks for CTO cases : A) Start with CTO wires with support of 4F Fine cross Micro catheter (Terumo).   B) Use Fielder XT (Hydrophilic coated with tapered end) to cross CTO with micro channels or in tortuous calcified vessels, it slides down the stenosis. Fine cross micro catheter gives support to wire, useful to change CTO wire over doc extension to BMW wire once CTO lesion is crossed. Perforations distally are more common with Polymer coated tapered wires like Fielder XT or whisper wire.  

C) For hard Fibrotic cap in CTO use hard tip wires like Miracle (3-6-9-12 gms), conquest or Proconquest wires (8-20 gms) wizard wire (3-6 gms).   D) Advance fine cross micro catheter helps to puncture the CTO with increasing stiffer wires from 3-12gms miracle or a 8 to 20 gms conquest/ Proconquest wires.   Japanese techniques, tips and tricks for CTO cases :

E) 4F fine cross micro catheter used in CTO has the following advantages:   I) Gives support to wire to cross. II) Useful to change various increasing stiffer CTO wires over doc extension. III) Change over to BMW wire once lesion is crossed. IV) Once micro catheter crosses the CTO it dilates the CTO & makes it a 90% stenosis. V) Once you take fine cross micro catheter down aspiration with 2ml dye syringe & inject through fine cross to be sure you are in true lumen distally. Japanese techniques, tips and tricks for CTO cases :

F) To get guide catheter support put a parallel anchor wire in the side branch or even inflate a 2mm anchor balloon in side branch. This will make guide catheter stable for support which is a must in CTO cases.   G) Go mm by mm with CTO wire rotate softly clockwise & counter clockwise & eventually the wire will enter the micro channels and get caught in the micro channels. Have lot patience and persistence while puncturing the proximal fibrous cap , entry in the micro channel and body of the CTO and finally puncturing the distal fibrous cap which is most difficult. Japanese techniques, tips and tricks for CTO cases :

H) To know distally if you are in a false channel , make angio from the opposite donor artery and you will see the distal collateral and the distal position of the wire whether in true or false lumen. Also free movement of wire means you are in true lumen.   I) Keep pressure on balloon in CTO every 3 minutes the balloon moves 1mm.   J) Crossed catheter (like fine cross) in a channel dilator. It is covered with Tungsten and to be moved counter clockwise to create a lumen at site of CTO.   Japanese techniques, tips and tricks for CTO cases :

K) Once CTO is crossed and dilated with fine cross micro catheter and distal wire is in true lumen then balloon dilatation and stenting is easy.   L) This Antigrade approach works in 90% of cases in crossing CTO & is the preferred technique, retrograde approaches are more complicated.   M) STAR (Creating sub intimal dissection with stiff wires and reentry in true lumen) and CART ( Controlled antigrade & retrograde subintimal tracking techniques) are more difficult and prone to Perforations and other dreadful complications.  Japanese techniques, tips and tricks for CTO cases :

Cases : Sakaria, Arjanbhai Madhabhai (52 yrs/M)

I am Open to Questions…