1. OCT GUIDANCE FOR CTO AVINGER
RICHARD R. HEUSER, MD, FACC, FACP, FESC, FSCAI
Chief of Cardiology, St. Luke’s Medical Center,
Phoenix, Arizona
Professor of Medicine, Univ. of Arizona
College of Medicine, Phoenix, Arizona

2. Richard R. Heuser, MD Consulting: Abbott Vascular and ev3, Inc.
Honoraria: Abiomed, Inc., Bard Peripheral Vascular, Inc., Medtronic, Inc. and Spectranetics Corporation
Stocks, Stock Options, other ownership interest: QuantumCor, Inc., PQBypass and CSI.

7. A 56 year old transgender female presents with a three month history of a 4x5 centimeter, non-healing ulcer on the dorsum of the foot. She had previously been diagnosed as having an idiopathic cardiomyopathy. She has had a history of hyperlipidemia and tobacco abuse. When eliciting a history, the patient admits to classic claudication bilaterally. We were asked to see the patient because of the question of possible cardiac clearance prior to amputation. Instead we decided to perform angiography.

8. Four Physicians Failed to Diagnose PVD
Her Cardiologist
The Hospitalist
The infectious disease specialist
The wound care specialist (Orthopedic Surgeon)

9. Take a Good History

15. A 57 year old female presented right arm claudication
A 57 year old female presented right arm claudication. Her risk factors for coronary disease include chronic tobacco use and hyperlipidemia. The right axillary occlusion has been present for at least six years. She saw a vascular surgeon six years prior to admission who performed angiography and told her nothing could be done for her occlusion.

23. The Value of OCT Guided Crossing Devices in Challenging CTOs

24. Current modalities for vascular imaging
IVUIVUS
(Intravascular Ultrasound)
OOCT
(Optical Coherence Tomography)
Good visualization through blood
Resolution (~100 – 300 µm)
Depth penetration (~5 – 7 mm)
Limited visualization through blood
Resolution (~10 – 20 µm)  10X IVUS
Depth Penetration(~2 – 3 mm)

25. The OCT approach to CTOs
The Ocelot Catheter (Avinger, Redwood City, CA)

26. Ocelot Catheter redefines CTO crossing with OCT image guidance
Middle Marker + Layered Structures
Rotate
Position Middle Marker over Layered Structures
Advance
Until you need to image or rotate again

27. Catheter and visualization device make up a 4 part system
Ocelot System
Catheter and visualization device make up a 4 part system
(Avinger, Redwood City, CA)

29. Improved stand alone crossing success using OCT
72%
EXPERIENCE MATTERS
72% - MEAN CONNECT II OCELOT ALONE CROSSING SUCCESS
TOTAL OCELOT EXPERIENCE LEADS TO STAND ALONE OCELOT SUCCESS IN CONNECT II
Ocelot Experience^
n < 2
n = 6
n >15
Patients treated
n = 22
n = 100
n = 53
Number of sites
n = 13
n = 14
n = 4
*C2 sites enrolling greater than 15 patients + commercial
OUS C2 sites with previous Ocelot experience greater than 15 patients
^indicates average Ocelot use per site

30. Reduced CTO crossing times using OCT
EXPERIENCE MATTERS
33 min
33 MINS - MEAN CONNECT II CTO CROSSING TIMETOTAL OCELOT EXPERIENCE LEADS TO REDUCED CTO CROSSING TIMES IN CONNECT II
Ocelot Experience^
n < 2
n = 6
n > 15
Patients treated
n = 201
n = 972
n = 53
Number of sites
n = 13
n = 14
n = 4
*C2 sites enrolling greater than 15 patients + commercial
OUS C2 sites with previous Ocelot experience greater than 15 patients
^indicates average Ocelot use per site
1excludes 2 patients where CTO crossing was unsuccessful
2excludes 3 patients where CTO crossing was unsuccessful

31. Reduced fluoroscopy when crossing CTOs using OCT
39 min
EXPERIENCE MATTERS
39 MINS - MEAN CONNECT II PROCEDURE FLUOROSCOPY TIME
TOTAL OCELOT EXPERIENCE LEADS TO REDUCED FLUOROSCOPY TIMES IN CONNECT II
Ocelot Experience^
n < 2
n = 6
n >15
Patients treated
n = 22
n = 100
n = 53
Number of sites
n = 14
n = 14
n = 4
*C2 sites enrolling greater than 15 patients + commercial
OUS C2 sites with previous Ocelot experience greater than 15 patients
^indicates average Ocelot use per site

32. Value of OCT OCT enables:
Real time image guidance for directionality during CTO crossing
Assessment of true luminal crossing
A new perspective to guide patient tailored therapies
Improved stand alone crossing (CONNECT II)
Reduced CTO crossing times (CONNECT II)
Reduced fluoroscopy during CTO crossing (CONNECT II)

33. See. Navigate. Cross. Patient Information - 59 Year old female
- Smoker
- Diabetic
- Hypertension
- CAD
- Lifestyle limiting claudication
- 30 cm, SFA, CTO

34. Entering proximal cap, middle marker in the wrong position
Using Ocelot’s real-time, intravascular imaging via optical coherence tomography, OCT
Layered Structures
Non-layered Structures
Entering proximal cap, middle marker in the wrong position

35. Ocelot’s 3 marker system and pre-shaped tip facilitate intravascular orientation
Middle marker over layered structures
Ocelot deflected
toward non-layered
structures
Mid SFA, middle marker now in the right position

36. Using Ocelot’s unique spiral wedges to corkscrew through CTO
Ocelot enters true distal lumen creating “Starburst.” (Blood and saline mixture)

37. Case Outcomes - Crossing time: 12:37 - 30 cm CTO - Silverhawk
- Angioplasty

39. Conclusion
The Wildcat device has saved us time and has replaced the Glide wire glide catheter techniques in most of our CTOs.
The blunt tip reminds me of the early Magnum wire and works similar to the CrossBoss catheter
The Juicebox made CTOs a lot easier and saved on finger fatigue.
The Ocelot has made peripheral CTOs a lot safer and improved potential outcomes.
The next step is coronary CTOs.