A t dA t d II ti l dti l d S bi ti lS bi ti lAntegradeAntegrade IIntimal and ntimal and SubintimalSubintimalAngioplastyAngioplastyg p yg p y

Osami Kawarada MD FSCAIOsami Kawarada, MD, FSCAIDepartment of Cardiovascular Medicine

National Cerebral and Cardiovascular CenterNational Cerebral and Cardiovascular CenterOsaka, Japan

M lti essel Long Occl si e DiseaseMultivessel Long Occlusive Disease

Kawarada O, et al. Catheter Cardiovasc Interv 2011; 78:1051–1058.

A BOne Straight-Line flowA BOne Straight Line flow

Pre Post

Procedural Steps of Infrapopliteal CTOProcedural Steps of Infrapopliteal CTO Crossing Technique

Antegrade approachAntegrade approach

DrillingParallel wire L t h iDrilling technique

Parallel wire technique

Loop technique

Retrograde approach

T ll t lT ll t l T d l hT d l hTranscollateral approach

Transcollateral approach

Transpedal arch approach

Transpedal arch approach

Procedural Steps of Infrapopliteal CTOProcedural Steps of Infrapopliteal CTO Crossing Technique

Antegrade approachAntegrade approach

DrillingParallel wire L t h iDrilling technique

Parallel wire technique

Loop technique

Retrograde approach

T ll t lT ll t l T d l hT d l hTranscollateral approach

Transcollateral approach

Transpedal arch approach

Transpedal arch approach

T l B I f lit l CTO I t tiTool Box : Infrapopliteal CTOs Intervention

• Ipsilateral antegrade approach p g pp

• 4F “long” sheath (30-45cm)

• 0.014 >0.010 or 0.018 inch guidewire

• OTW balloon catheter > microcatheter

CTO R li ti T h i 1CTO R li ti T h i 1CTO Recanalization Technique 1 CTO Recanalization Technique 1 Conventional Coronary Technique Conventional Coronary Technique y qy q

54 years/old, Male, Rutherford5, HD

Pre

Calcified CTO

0.014 CTO GW supported by OTW

Pre PostPre Post

SPP 60/74 mmHg

SPP 24/25 mmHg

CTO R li ti T h i 2CTO R li ti T h i 2CTO Recanalization Technique 2 CTO Recanalization Technique 2 Parallel Wire Technique Parallel Wire Technique qq

Pre 1st GW 2nd GW Post

CTO R li ti T h i 3CTO R li ti T h i 3CTO Recanalization Technique 3 CTO Recanalization Technique 3 Loop Technique Loop Technique p qp q

((SubintimalSubintimal angioplasty, Knuckle wire) angioplasty, Knuckle wire)

A BA B

Pre Post0.014 “floppy” GW supported by OTW

CTO R li ti T h i 4CTO R li ti T h i 4CTO Recanalization Technique 4 CTO Recanalization Technique 4 Penetration Technique Penetration Technique qq

L t h iPre

Loop techniquePenetration Post

Endovascular procedure has significantly developed d i th l t d dduring the last decade.

The combination of these techniques can make a huge q gdifference in the treatment of infrapopliteal CTOs.

Buerger’s Disease

Non-atherosclerotic disease, Buerger’s disease patients might be able to enjoy endovascular therapy.

37 y/o Male, Smoker, Buerger’s Disease

2007

y , , g이미지를 표시할 수 없습니다 . 컴퓨터 메모리가 부족하여 이미지를 열 수없거나 이미지가 손상되었습니다 . 컴퓨터를 다시 시작한 후 파일을 다시 여십시오 . 여전히 빨간색 x가 나타나면 이미지를 삭제한 다음 다시 삽입해야 합니다 .

L t h i PostPre Loop technique

Pre Post3 months

이미지를 표시할 수없습니다 . 컴퓨터 메모리가 부족하여 이미지를 열수 없거나 이미지가 손상되었습니다 . 컴퓨터를 다시 시작한 후파일을 다시여십시오 . 여전히 빨간색 x가나타나면 이미지를 삭제한 다음 다시 삽입해야 합니다 .

4 years

Fig138 y/o Female, Smoker, Buerger’s Diseaseg

A

y , , g

Extensive tissue loss after distal bypass occlusion

Kawarada O, et al. J Endovasc Ther 2013 (in press)

Fig 4g

Standard Loop

0.014 floppy GWGW

Kawarada O, et al. J Endovasc Ther 2013 (in press)

Kawarada O, et al. J Endovasc Ther 2013 (in press)

5 months

Fig8Conclusions

• Showcases of antegrade infrapopliteal CTO recanalizationShowcases of antegrade infrapopliteal CTO recanalization techniques on the atherosclerotic population basis.

• Liberal application of contemporary endovascular therapy to Buerger’s disease.