Chronic total occlusion treated with coronary intervention by three-dimensional guidewire manipulation: an experimental
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CASE REPORT
Chronic total occlusion treated with coronary intervention by three-dimensional guidewire manipulation: an experimental study and clinical experience Atsunori Okamura1 • Katsuomi Iwakura1 • Hiroyuki Nagai1 • Katsutoshi Kawamura1 Tomohiro Yamasaki1 • Kenshi Fujii1
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Received: 5 February 2015 / Accepted: 11 June 2015 Japanese Association of Cardiovascular Intervention and Therapeutics 2015
Abstract Three-dimensional (3D) wiring is one method for accurate guidewire control in chronic total occlusion (CTO) lesions during manipulation of CTO-specific stiff guidewires. However, the construction of a mental 3D image is difficult. We propose the idea of image patterns to allow immediate construction of 3D images from the two perpendicular angles of the X-ray system detector and report a case of CTO treated with 3D wiring. Keywords Chronic total occlusion CTO-specific stiff guidewires 3D wiring
Introduction Chronic total occlusion (CTO)-specific stiff guidewires, e.g., GAIA (Katoh and Asahi Intec, Aichi, Japan) and Conquest (Asahi Intec) [1], have been approved for percutaneous coronary intervention (PCI) in CTO in most countries. These guidewires enable accurate control in CTO lesions with \90 rotation. Sufficient torque for rotation even in CTO lesions can advance them to the ideal position in the CTO body and penetrate the CTO exit with the ideal tip direction. Unintentional rotation without an image of clockwise/counterclockwise rotation will create a larger space in CTO lesions, resulting in failure of lesion crossing. Accurate guidewire control is crucial, but is sometimes difficult with a two-dimensional (2D) image. We developed a CTO-specific intravascular ultrasound & Atsunori Okamura [email protected] 1
Division of Cardiology, Sakurabashi Watanabe Hospital, 2-4-32 Umeda, Kita-ku, Osaka 530-0001, Japan
(IVUS) system, Navifocus WR, in partnership with Terumo Corp. (Tokyo, Japan) [2]. Our clinical experience with IVUS-guided wiring for CTO lesions indicated that the three-dimensional (3D) image is important for accurate guidewire control. Therefore, we have performed real-time 3D wiring using the two perpendicular angles of the X-ray system detector without IVUS guidance. However, construction of a mental 3D image is difficult and takes time during PCI. We propose the idea of image patterns for immediate construction of 3D images from the two perpendicular angles of the X-ray system detector and show 3D wiring using the heartbeat model to confirm its feasibility and reproducibility. We report a case of CTO treated with 3D wiring.
Image patterns to achieve ideal guidewire rotation At the CTO entrance, 2D wiring is sufficient because it is difficult to control guidewires accurately in the blood-filled lumen. At the CTO body, 3D wiring is useful except in cases where we cannot create the route image or the guidewires are likely to enter the sub-intima. At the CTO exit, 3D wiring is necessary for pinpoint puncture of the exit. Figure 1a shows 3D wiring in a mid-right coronary artery
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