Satoru Sumitsuji – How to apply histologic information in retrograde approach without IVUS nor CT
2. 【Invited Lecture & PCI Workshop Map】
2013 (33)
January Taiwan
February Egypt・Indonesia・USA
March Hong Kong・Taiwan・China
April Malaysia・Italy・Philippines・Bangladesh
May UAE・KSA・Taiwan・China・Hong Kong
June
July Malaysia
August China・Korea
September Colombia・Switzerland・France・UAE
October Indonesia・USA
November Kuwait・Oman・Malaysia・Thailand・China x2
December Singapore・Taiwan
2014 (39)
January Korea・Singapore・China
February India・UAE・Hong Kong・USA
March Hong Kong・China
April Taiwan・Bangladesh・Korea
May Egypt・China・Kuwait
June Jordan・Taiwan
July
August USA・Egypt・Jordan・UAE
September USA・China
October Malaysia・Kuwait・UAE・Korea・China
November China・Egypt・Colombia・UAE・Indonesia
December Bangladesh・Singapore・Kuwait・UAE・Indonesia・
Tunisia
17. IVUS : Retrograde
Antegrade wire
Intimal Plaque Subintima
Retrograde
wire
Intimal
Plaque
Retrograde wiring &
Antegrade ballooning or
Direct puncture
Retrograde wiring &
More proximal connection
or Original CART
Subintima
Antegrade ballooning
or
More distal connection
Antegrade ballooning
A
R
A
R
A
R
A
R
18. IVUS : Retrograde
Antegrade wire
Intimal Plaque Subintima
Retrograde
wire
Intimal
Plaque
Retrograde wiring &
Antegrade ballooning or
Direct puncture
Retrograde wiring &
More proximal connection
or Original CART
Subintima
Antegrade ballooning
or
More distal connection
Antegrade ballooning
A
R
A
R
A
R
A
R
PP SP
PS SS
19. IVUS : Retrograde
Antegrade wire
Intimal Plaque Subintima
Retrograde
wire
Intimal
Plaque
Antegrade ballooning
and
Retrograde wiring
Retrograde wiring
and
More proximal connection
Subintima
Antegrade ballooning
or
More distal connection
Antegrade ballooning
A
R
A
R
A
R
A
R
SS
20. IVUS : Retrograde
Antegrade wire
Intimal Plaque Subintima
Retrograde
wire
Intimal
Plaque
Antegrade ballooning
and
Retrograde wiring
Retrograde wiring
and
More proximal connection
Subintima
Antegrade ballooning
or
More distal connection
Antegrade ballooning
A
R
A
R
A
R
A
R
21. IVUS : Retrograde
Antegrade wire
Intimal Plaque Subintima
Retrograde
wire
Intimal
Plaque
Antegrade ballooning
and
Retrograde wiring
Retrograde wiring
and
More proximal connection
Subintima
Antegrade ballooning
or
More distal connection
Antegrade ballooning
A
R
A
R
A
R
A
R
22. IVUS : Retrograde
Antegrade wire
Intimal Plaque Subintima
Retrograde
wire
Intimal
Plaque
Antegrade ballooning
and
Retrograde wiring
Retrograde wiring
and
More proximal connection
Subintima
Antegrade ballooning
or
More distal connection
Antegrade ballooning
A
R
A
R
A
R
A
R
PS
23. IVUS : Retrograde
Antegrade wire
Intimal Plaque Subintima
Retrograde
wire
Intimal
Plaque
Antegrade ballooning
and
Retrograde wiring
Retrograde wiring
and
More proximal connection
Subintima
Antegrade ballooning
or
More distal connection
Antegrade ballooning
A
R
A
R
A
R
A
R
24. IVUS : Retrograde
Antegrade wire
Intimal Plaque Subintima
Retrograde
wire
Intimal
Plaque
Antegrade ballooning
and
Retrograde wiring
Retrograde wiring
and
More proximal connection
Subintima
Antegrade ballooning
or
More distal connection
Antegrade ballooning
A
R
A
R
A
R
A
R
DISTAL
25. IVUS : Retrograde
Antegrade wire
Intimal Plaque Subintima
Retrograde
wire
Intimal
Plaque
Antegrade ballooning
and
Retrograde wiring
Retrograde wiring
and
More proximal connection
Subintima
Antegrade ballooning
or
More distal connection
Antegrade ballooning
A
R
A
R
A
R
A
RDISTAL
DISTAL
26. IVUS : Retrograde
Antegrade wire
Intimal Plaque Subintima
Retrograde
wire
Intimal
Plaque
Antegrade ballooning
and
Retrograde wiring
Retrograde wiring
and
More proximal connection
Subintima
Antegrade ballooning
or
More distal connection
Antegrade ballooning
A
R
A
R
A
R
A
RDISTAL
DISTAL
27. IVUS : Retrograde
Antegrade wire
Intimal Plaque Subintima
Retrograde
wire
Intimal
Plaque
Retrograde wiring &
Antegrade ballooning or
Direct puncture
Retrograde wiring
and
More proximal connection
Subintima
Antegrade ballooning
or
More distal connection
Antegrade ballooning
A
R
A
R
A
R
A
R
PP
28. IVUS : Retrograde
Antegrade wire
Intimal Plaque Subintima
Retrograde
wire
Intimal
Plaque
Antegrade ballooning
and
Retrograde wiring
Retrograde wiring
and
More proximal connection
Subintima
Antegrade ballooning
or
More distal connection
Antegrade ballooning
A
R
A
R
A
R
A
R
29. IVUS : Retrograde
Antegrade wire
Intimal Plaque Subintima
Retrograde
wire
Intimal
Plaque
Antegrade ballooning
and
Retrograde wiring
Retrograde wiring
and
More proximal connection
Subintima
Antegrade ballooning
or
More distal connection
Antegrade ballooning
A
R
A
R
A
R
A
R
30. IVUS : Retrograde
Antegrade wire
Intimal Plaque Subintima
Retrograde
wire
Intimal
Plaque
Antegrade ballooning
and
Retrograde wiring
Retrograde wiring
and
More proximal connection
Subintima
Antegrade ballooning
or
More distal connection
Antegrade ballooning
A
R
A
R
A
R
A
R
PUNCTURE!
31. IVUS : Retrograde
Antegrade wire
Intimal Plaque Subintima
Retrograde
wire
Intimal
Plaque
Retrograde wiring &
Antegrade ballooning or
Direct puncture
Retrograde wiring
and
More proximal connection
Subintima
Antegrade ballooning
or
More distal connection
Antegrade ballooning
A
R
A
R
A
R
A
R
PROXIMAL
32. IVUS : Retrograde
Antegrade wire
Intimal Plaque Subintima
Retrograde
wire
Intimal
Plaque
Retrograde wiring &
Antegrade ballooning or
Direct puncture
Retrograde wiring
and
More proximal connection
Subintima
Antegrade ballooning
or
More distal connection
Antegrade ballooning
A
R
A
R
A
R
A
R
PROXIMAL
PROX
33. IVUS : Retrograde
Antegrade wire
Intimal Plaque Subintima
Retrograde
wire
Intimal
Plaque
Retrograde wiring &
Antegrade ballooning or
Direct puncture
Retrograde wiring
and
More proximal connection
Subintima
Antegrade ballooning
or
More distal connection
Antegrade ballooning
A
R
A
R
A
R
A
R
PROX
PROXIMAL
34. IVUS : Retrograde
Antegrade wire
Intimal Plaque Subintima
Retrograde
wire
Intimal
Plaque
Antegrade ballooning
and
Retrograde wiring
Retrograde wiring &
More proximal connection
or Original CART
Subintima
Antegrade ballooning
or
More distal connection
Antegrade ballooning
A
R
A
R
A
R
A
R
SP
35. IVUS : Retrograde
Antegrade wire
Intimal Plaque Subintima
Retrograde
wire
Intimal
Plaque
Antegrade ballooning
and
Retrograde wiring
Retrograde wiring &
More proximal connection
or Original CART
Subintima
Antegrade ballooning
or
More distal connection
Antegrade ballooning
A
R
A
R
A
R
A
R
36. IVUS : Retrograde
Antegrade wire
Intimal Plaque Subintima
Retrograde
wire
Intimal
Plaque
Antegrade ballooning
and
Retrograde wiring
Retrograde wiring &
More proximal connection
or Original CART
Subintima
Antegrade ballooning
or
More distal connection
Antegrade ballooning
A
R
A
R
A
R
A
R
1
PROXIMAL
37. IVUS : Retrograde
Antegrade wire
Intimal Plaque Subintima
Retrograde
wire
Intimal
Plaque
Antegrade ballooning
and
Retrograde wiring
Retrograde wiring &
More proximal connection
or Original CART
Subintima
Antegrade ballooning
or
More distal connection
Antegrade ballooning
A
R
A
R
A
R
A
R
PROXIMAL
PROX
PROX
38. IVUS : Retrograde
Antegrade wire
Intimal Plaque Subintima
Retrograde
wire
Intimal
Plaque
Antegrade ballooning
and
Retrograde wiring
Retrograde wiring &
More proximal connection
or Original CART
Subintima
Antegrade ballooning
or
More distal connection
Antegrade ballooning
A
R
A
R
A
R
A
R
PUNCTURE!
PROXIMAL
PROX
PROX
39. IVUS : Retrograde
Antegrade wire
Intimal Plaque Subintima
Retrograde
wire
Intimal
Plaque
Antegrade ballooning
and
Retrograde wiring
Retrograde wiring &
More proximal connection
or Original CART
Subintima
Antegrade ballooning
or
More distal connection
Antegrade ballooning
A
R
A
R
A
R
A
R
40. How should we do w/o IVUS
Always we try to do reverse CART at closest point.
But sometimes failed even using bigger balloon…
A R
A
R
A
R
PP SP
PS SS
A R
41. How should we do w/o IVUS
Always we try to do reverse CART at closest point.
How bigger size balloon work???
A R
A
R
A
R
A R
PP SP
PS SS
YES!?
YES? / NO
YES!!!
NO!!!
42. How should we do w/o IVUS
Always we try to do reverse CART at closest point.
How bigger size balloon work???
A R
A
R
A
R
A R
PP SP
PS SS
YES / NO!
YES!!!
NO!!!
YES!?
43. How should we do w/o IVUS
Always we try to do reverse CART at closest point.
How bigger size balloon work???
A R
A
R
A
R
A R
PP SP
PS SS
YES !
YES / NO!
YES !
NO !!!
44. IVUS : Retrograde
Antegrade wire
Intimal Plaque Subintima
Retrograde
wire
Intimal
Plaque
Antegrade ballooning
and
Retrograde wiring
Retrograde wiring
and
More proximal connection
Subintima
Antegrade ballooning
or
More distal connection
Antegrade ballooning
A
R
A
R
A
R
A
R
45. IVUS : Retrograde
Antegrade wire
Intimal Plaque Subintima
Retrograde
wire
Intimal
Plaque
Antegrade ballooning
and
Retrograde wiring
Retrograde wiring
and
More proximal connection
Subintima
Antegrade ballooning
or
More distal connection
Antegrade ballooning
A
R
A
R
A
R
A
R
PUNCTURE!
46. IVUS : Retrograde
Antegrade wire
Intimal Plaque Subintima
Retrograde
wire
Intimal
Plaque
Retrograde wiring &
Antegrade ballooning or
Direct puncture
Retrograde wiring
and
More proximal connection
Subintima
Antegrade ballooning
or
More distal connection
Antegrade ballooning
A
R
A
R
A
R
A
R
PROXIMAL
47. IVUS : Retrograde
Antegrade wire
Intimal Plaque Subintima
Retrograde
wire
Intimal
Plaque
Retrograde wiring &
Antegrade ballooning or
Direct puncture
Retrograde wiring
and
More proximal connection
Subintima
Antegrade ballooning
or
More distal connection
Antegrade ballooning
A
R
A
R
A
R
A
R
PROXIMAL
PROX
48. IVUS : Retrograde
Antegrade wire
Intimal Plaque Subintima
Retrograde
wire
Intimal
Plaque
Retrograde wiring &
Antegrade ballooning or
Direct puncture
Retrograde wiring
and
More proximal connection
Subintima
Antegrade ballooning
or
More distal connection
Antegrade ballooning
A
R
A
R
A
R
A
R
PROX
PROXIMAL
49. How should we do w/o IVUS
Always we try to do reverse CART at closest point.
How bigger size balloon work???
A R
A
R
A
R
A R
PP SP
PS SS
YES !
YES / NO !
YES !
NO !!!
50. IVUS : Retrograde
Antegrade wire
Intimal Plaque Subintima
Retrograde
wire
Intimal
Plaque
Antegrade ballooning
and
Retrograde wiring
Retrograde wiring &
More proximal connection
or Original CART
Subintima
Antegrade ballooning
or
More distal connection
Antegrade ballooning
A
R
A
R
A
R
A
R
51. IVUS : Retrograde
Antegrade wire
Intimal Plaque Subintima
Retrograde
wire
Intimal
Plaque
Antegrade ballooning
and
Retrograde wiring
Retrograde wiring &
More proximal connection
or Original CART
Subintima
Antegrade ballooning
or
More distal connection
Antegrade ballooning
A
R
A
R
A
R
A
R
1
PROXIMAL
52. IVUS : Retrograde
Antegrade wire
Intimal Plaque Subintima
Retrograde
wire
Intimal
Plaque
Antegrade ballooning
and
Retrograde wiring
Retrograde wiring &
More proximal connection
or Original CART
Subintima
Antegrade ballooning
or
More distal connection
Antegrade ballooning
A
R
A
R
A
R
A
R
PROXIMAL
PROX
PROX
53. IVUS : Retrograde
Antegrade wire
Intimal Plaque Subintima
Retrograde
wire
Intimal
Plaque
Antegrade ballooning
and
Retrograde wiring
Retrograde wiring &
More proximal connection
or Original CART
Subintima
Antegrade ballooning
or
More distal connection
Antegrade ballooning
A
R
A
R
A
R
A
R
PUNCTURE!
PROXIMAL
PROX
PROX
54. IVUS : Retrograde
Antegrade wire
Intimal Plaque Subintima
Retrograde
wire
Intimal
Plaque
Antegrade ballooning
and
Retrograde wiring
Retrograde wiring &
More proximal connection
or Original CART
Subintima
Antegrade ballooning
or
More distal connection
Antegrade ballooning
A
R
A
R
A
R
A
R
55. How should we do w/o IVUS
After failure of reverse CART with bigger balloon, I
still don’t have best solution…
A R
A
R
A
R
A R
PP SP
PS SS
YES / NO!
YES!!!
NO!!!
YES!?
56. Summary
Reverse CART should be tried at closest point of two
wires with certain size of balloon.
Even bigger balloon doesn’t work, it means the
situation of wires are PP or SP.
PP needs puncture at the point or advance retro GW
which change situation to PS.
SP needs advance of retro GW to get PP or SS, or do
CART.
Correct estimation is key to success but… not easy…
57. Summary
Reverse CART should be tried at closest point of two
wires with certain size of balloon.
Even bigger balloon doesn’t work, it means the
situation of wires are PP or SP.
PP needs puncture at the point or advance retro GW
which change situation to PS.
SP needs advance of retro GW to get PP or SS, or do
CART.
Correct estimation is key to success but… not easy…
So I strongly recommend use IVUS in tough situation!