第20届GWICC转播病例 Revascularization of Ostial LAD CTO with Combined Use of Retrograde and Antegrade Wire Techniques 逆行＋正向导丝技术在LAD CTO血运重建中的应用 Li Weiming, Xu Yawei 李伟明 徐亚伟 Revascularization of Ostial LAD CTO with Combined Use of Retrograde and Antegrade Wire Technique 逆行加正向导丝技术在LAD开口CTO病变血运重建中的应用 Department of Cardiology,Shanghai Tenth People’s Hospital of Tongji University CIT2010-March,2010,Beijing

Case History Present History Male,77yr 2 years ago: Chest uncomfortable, CAG showed LAD CTO, and tried to revascularize, but failed; pLCX 90% stenosis, implanted one stent 2 months ago: Exertional chest uncomfortable. CAG showed that LCX was OK, ostial LAD was also occlude, but failed to revascularize again This time: Try to revascularize the LAD using Retrograde Wire Techniques

Case History Risk Factors HBP for several years，be controlled well,No DM PE P76bpm,R16bpm,BP132/72mmHg;heart/lung negative Blood biochemistry and main Associated Examinations Laboratory tests:Normal hepatic and renal function.Normal FPG,myocardial necrotic markers and BNP Resting ECG：SR，68bpm A chest X-ray film：normal Echocardiography：Light MV regurgitation and decreased LV diastolic function

LCX:no in-stent restenosis; LAD:ostial CTO CAG 2009.8.6 LCX:no in-stent restenosis; LAD:ostial CTO

LCX:no in-stent restenosis; LAD:ostial CTO CAG 2009.8.6 LCX:no in-stent restenosis; LAD:ostial CTO

CAG 2009.8.6 RCA: dominant and strong artery,no severe stenosis, well collateral circuIation to dLAD RCA血管粗大，呈现右优势型，可见丰富的侧支循环供应LAD分布区

CAG 2009.8.6 RCA: dominant and strong artery,no severe stenosis, weill collateral circuIation to dLAD

Try to Revascularize LAD 2009.8.6 GC:6FXB3.5; Microcatheter:2F Progreat; GW:Conquest Pro. It couldn’t breakthrough the CTO

Try to Revascularize LAD 2009.8.6

Diagnosis CHD, extensive anterior OMI, LAD CTO, 2yr later of LCX stenting, ACS, NYHA 1-2 Hypertension, Very high risk

The therapy strategies this time Medical Therapy CABG PCI Antegrade Wire Crossing Technique Retrograde Wire Crossing Technique

Revascularization of LAD 2009.10.9 Pathways of Revascularization Right femoral artery: Pathway of Retrograde Wire Technique for revascularization Left femoral artery: Pathways of CAG and Antegrade Wire Technique

Revascularization of LAD 2009.10.9 Instruments be chosen RCA LM/LAD/LCX GC 7F AL1 7F EBU3.75 Retro-wire 0.014″Fielder FC 0.009″Conquest Pro Ante-wire 0.014″Rinato Protection wire Runthrough（LCX） Micro-catheter 1.8F Finecross 指引导管 LM：7F EBU3.75；RCA：7F AL1 导 丝 0.014″Field FC，微导管：1.8F Finecross。两者配合，必要时从微导管造影以明确导丝远段的位置和方向；导丝较为顺利地经RCA后降支进入LAD间隔支，进而逆向上行至LAD中远段－角支分叉处，微导管紧紧跟进；继续操作导丝，导丝抵达闭塞病变远端，阻力明显增加，导丝难以继续前进（图22-13-3）。随后，经微导管更换较硬的导丝Conquest Pro

Revascularization of LAD GC: 7F EBU3.75 (left),7F AL1 (right) Bilateral CAG：well collateral circuIation from RCA to dLAD

Revascularization of LAD GW:0.014″Field FC. It retrograded slowly via the septal branch to the distal end of CTO. The tip of GW was confirmed in the true lumen by Angiography via the microcatheter

Revascularization of LAD The GW of Field FC continued to retrograde slowly

Revascularization of LAD But it met resistance in the middle of CTO

Revascularization of LAD Changing the GW to Conquest Pro via microcatheter. Then the GW continued to retrograde slowly

Revascularization of LAD In order to avoid the procedure-related injury,a Runthrough GW was preimplanted as a protection wire and it also was confirmed in the true lumen by bilateral angiography LCX保护导丝 RCA逆行导丝

Revascularization of LAD The GW retrograde, and nearly crossed over the fibrous cap of LAD CTO

Revascularization of LAD The GW crossed over the fibrous cap of CTO, and entered into the LM at last

Revascularization of LAD The GW reached the LM at last, but it couldn’t enter into the GC PCI13

Revascularization of LAD Antegrade Wire Technique: Under the direction of the retrograde wire,the GW of Conquest Pro reached the middle LAD in the support of the microcatheter, and was confirmed in the true lumen 14 顺向导丝技术：导丝Conquest Pro以微导管作保护和支撑，以逆行导丝为路标，不断调整方向抵达LAD中段，微导管造影证实在血管真腔内

Revascularization of LAD Under the direction of the retrograde wire, the Conquest Pro advanced slowly 15

Revascularization of LAD Under the direction of the retrograde wire, the Conquest Pro advanced slowly 16

Revascularization of LAD When the antegrade wire reached the middle LAD, it was changed to the Rinato. The soft wire was sent to the distal LAD later. 20

Revascularization of LAD The antegrade wire in the distal LAD was confirmed in the true lumen by angiography through the microcatheter 21

Revascularization of LAD Send the Rinato to the distal LAD, then partly withdrew the retrograde wire and the microcatheter

Revascularization of LAD Predilatated the CTO of LAD using the small balloon (Firestar 1.510mm) from the distal to the proximal

Revascularization of LAD After predilatation using the small balloon 27

Revascularization of LAD Multi-predilatation using the bigger balloon （2.7525mm Sprinter）

Revascularization of LAD After predilatation using the bigger balloon

Revascularization of LAD One Endeavor DES（S1 2.524mm） was implanted in the mLAD at 14atm Second Endeavor DES（S2：2.7530mm）was implanted in the middle-proximal LAD 35

Revascularization of LAD The ostium of LAD was uncovered after two DES having been implanted 41

Revascularization of LAD S3（3.518mm）was implanted crossed over the ostial LCX at 14atm

Revascularization of LAD To kiss using the stent balloon（3.518mm）and the APEX balloon（3.015mm） The result was satisfied after kissing

Revascularization of LAD The distal LAD showed thin !

结果显示dLAD管腔本身细小，局部轻中度肌桥，未见明显的斑块和狭窄，不再植入支架 IVUS IVUS showed thin dLAD itself, and light myocardial bridge in the mLAD. No severe plaque and stenosis. No need of implanting any other stent 结果显示dLAD管腔本身细小，局部轻中度肌桥，未见明显的斑块和狭窄，不再植入支架

Final results 中段植入S1：2.524mm，近中段S2：2.7530mm，释放压均为14atm，支架释放良好，而LAD开口尚未覆盖。S3：3.518mm，跨越LCX开口，释放压14 atm，之后重置导丝，并以原支架球囊3.518mm和APEX球囊3.015mm进行对吻，最后造影结果十分满意，而LAD远段血管纤细，行IVUS检查，结果显示血管管腔本身细小，局部存在轻中度肌桥，未见明显的斑块和狭窄，因此没有再植入支架

Take Home Messages …… Transradial pathway nearly could complete any PCI procedures, but transfemoral pathway sometimes was much more convenient to the special case——PCI need not stick to the operation pathway ! No stump of CTO lesion in the ostial LAD. It seem to see the ostia only in the spider position. Usually it was difficult to find the true lumen of LAD using the antegrade wire technique. After having taken the lessons from the failure and having analyzed the complex lesions of CTO and the well collateral circulation from RCA, to select the retrograde wire technique is a wise choice——Clearly analyzing the lesions before PCI is very important 桡动脉径路近乎可以完成所有的PCI操作，而特殊病例仍以股动脉径路更为便利——PCI不必拘泥于手术径路 该LAD开口CTO病变没有残端，仅在蜘蛛位似可判断开口所在，顺向导丝技术导丝往往很难找到LAD真腔。有了失败的经历，仔细分析CTO病变和来自RCA的良好侧支循环，本次采用逆行导丝技术是明智之举——术前对病变的分析

Take Home Messages …… Having successfully revascularized the CTO of this case really benefit from the excellent devices,including the GW of Field FC/Conquest Pro,the GC of EBU3.75 and AL1,the microcatheter of 1.8F Finecross,the 1.510mm Firestar balloon,et al——A workman must sharpen his tools if he is to do his work well It is very important for the operator to agilitily apply and proficiently control the guiding wire, the microcatheter,and the balloon 本病例能成功血运重建，得益于精良的器械，包括Field FC/Conquest Pro导丝、EBU3.75和AL1指引导管、1.8F Finecross微导管、1.510mm的Firestar球囊等—— “工欲善其事”固然“必先利其器” 术者对导丝、球囊等器材的灵活运用和熟练驾驭至关重要

Thank you for your attention! 谢谢大家！ Thank you for your attention!