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Satoru Sumitsuji – How to apply histologic information in retrograde approach without IVUS nor CT
【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
Histological Key Points in RETRO
 Intimal Plaque / Subintima
 Loose Tissue
Basic Understandings
Intimal Plaque Media = Subintima
Adventitia
EEL: External Elastic Lamina
IEL: Internal Elastic Lamina
Basic Understandings
Intimal Plaque
Media = Subintima
False Lumen
True Lumen
Basic Understandings
Intimal Plaque
Media = Subintima
False Lumen
True Lumen
Basic Understandings
Intimal Plaque
Media = Subintima
= Intramural hematoma in IVUS
False Lumen
True Lumen
Basic Understandings
Intimal Plaque
Media = Subintima
= Intramural hematoma in IVUS
False Lumen
True Lumen
Basic Understandings
Intimal Plaque
Media = Subintima
= Intramural hematoma in IVUS
Collapsed True Lumen
False Lumen
Terminology with IVUS
Outside CTO
Intimal Plaque
Subintima
Subintima
Intimal Plaque
Terminology with IVUS
Inside CTO
Intimal Plaque
Subintima
Intimal Plaque
Subintima
Feature of Subintima
Sumitsuji et al. JACC Intv 2011; 9:941– 51
Subintimal tracking in antegrade
Sumitsuji et al. JACC Intv 2011; 9:941– 51
Subintimal tracking in antegrade
Sumitsuji et al. JACC Intv 2011; 9:941– 51
Key to success in antegrade approach is
“intimal plaque tracking”
Sumitsuji et al. JACC Intv 2011; 9:941– 51
Subintimal tracking in retrograde
Sumitsuji et al. JACC Intv 2011; 9:941– 51
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
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
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
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
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
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
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
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
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
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
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
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
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
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!
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
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
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
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
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
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
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
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
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
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
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!!!
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!?
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 !!!
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
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!
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
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
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
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 !!!
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
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
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
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
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
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!?
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…
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!
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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
  • 3. Histological Key Points in RETRO  Intimal Plaque / Subintima  Loose Tissue
  • 4. Basic Understandings Intimal Plaque Media = Subintima Adventitia EEL: External Elastic Lamina IEL: Internal Elastic Lamina
  • 5. Basic Understandings Intimal Plaque Media = Subintima False Lumen True Lumen
  • 6. Basic Understandings Intimal Plaque Media = Subintima False Lumen True Lumen
  • 7. Basic Understandings Intimal Plaque Media = Subintima = Intramural hematoma in IVUS False Lumen True Lumen
  • 8. Basic Understandings Intimal Plaque Media = Subintima = Intramural hematoma in IVUS False Lumen True Lumen
  • 9. Basic Understandings Intimal Plaque Media = Subintima = Intramural hematoma in IVUS Collapsed True Lumen False Lumen
  • 10. Terminology with IVUS Outside CTO Intimal Plaque Subintima Subintima Intimal Plaque
  • 11. Terminology with IVUS Inside CTO Intimal Plaque Subintima Intimal Plaque Subintima
  • 12. Feature of Subintima Sumitsuji et al. JACC Intv 2011; 9:941– 51
  • 13. Subintimal tracking in antegrade Sumitsuji et al. JACC Intv 2011; 9:941– 51
  • 14. Subintimal tracking in antegrade Sumitsuji et al. JACC Intv 2011; 9:941– 51
  • 15. Key to success in antegrade approach is “intimal plaque tracking” Sumitsuji et al. JACC Intv 2011; 9:941– 51
  • 16. Subintimal tracking in retrograde Sumitsuji et al. JACC Intv 2011; 9:941– 51
  • 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!
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