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Contributors
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SeijiHabara Habara Heart Clinic, Kurashiki, Japan
ShingoHosogi Hosogi Hospital, Kochi, Japan
KazushigeKadota Department of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan
HiroyukiTanaka Department of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan
Jutaro Yamada Department of Cardiology, Saiseikai Shimonoseki General Hospital,
Shimonoseki, Japan
TakehiroYamashita Department of Cardiology, Hokkaido Ohno Kinen Hospital, Sapporo,
Japan
KazuyoMitsudo, MD Health Care Plaza, Kurashiki Central Hospital, Kurashiki, Japan
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List of Columns
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Column 1 Guidewire Cannulation and Buddy Wire Techniques . . . . . . . . . . . . . . . . . . . 16
Column 2 Handling Coronary Arteries with Anomalous Origin . . . . . . . . . . . . . . . . . . . 17
Column 3 Fluoroscopy Angle and Detector Surface . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Column 4 Rotational Angiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Column 5 Advancing the Guidewire and Inuence of Tissue Hardness . . . . . . . . . . . . . 42
Column 6 Mechanisms of Guidewire Penetration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Column 7 Author’s Selection and Rationale: Part 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Column 8 Sion Guidewire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
Column 9 Techniques for the Middle and Distal RCA (Segments #2 and 3) . . . . . . . . . 119
Column 10 Selection and Rationale: Part 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Column 11 Distal Protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
Column 12 Stent Design and Stenting Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
Column 13 Good Versus Bad Fracture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
Column 14 Selection of the Balloon Type and Ination Pressure . . . . . . . . . . . . . . . . . . . 171
Column 15 Preventing Guidewire Entanglement and Countermeasures . . . . . . . . . . . . . . 174
Column 16 Balloon Rewrapping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
Column 17 Importance of the Correct Fluoroscopy Angle . . . . . . . . . . . . . . . . . . . . . . . . 189
Column 18 Necessity of Performing POT and KBI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
Column 19 Promus PREMIER Stent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
Column 20 Carina Shift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220
Column 21 Selection of the Lacrosse NSE, AngioSculpt, and ScoreFlex° balloons . . . . . 221
xvii
Mitsudo’s PCI Techniques forCTO
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1
1.1 Approach (Puncture Site)
There is still some controversy regarding the choice between
the transradial (TR) and transfemoral (TF) approaches for
intervention from the aspects of both preference and rationality. However, I do not think this is an essential matter. I
select the TR approach whenever possible because it is less
invasive irrespective of the PCI techniques I plan to use. I
always choose the TF approach to perform antegrade PCI for
CTO and PCI that can only be accomplished by stenting of a
bifurcation lesion in female patients. I do this because a largediameter guiding catheter is needed to achieve a “successful
outcome” in every patient when performing these procedures, although recanalization of a CTO via the TR approach
will be successful in many patients. The interventionalist’s
concept of a “successful outcome” may have a considerable
inuence on the choice between the two approaches. I select
the approach and the size of the guiding catheter according
to the rules described below.
1.1.1 Selection oftheApproach
1.1.1.1 Guiding Catheter Size
The smallest-diameter guiding catheter that can be used
is generally a good choice. I try to select a catheter with
the smallest diameter that allows me to perform all of the
PCI procedures that may be required for the target lesion
(Table1.1). Currently, a 7-Fr guiding catheter allows almost
all procedures to be accomplished, apart from rotablation
with a burr ≥2.15 mm in size. If a catheter with a larger
diameter becomes necessary while you are performing PCI,
you will need to replace both the catheter and the sheath with
larger ones or you may even have to abandon the planned
procedure. Conversely, you will never need to replace a
larger catheter with a smaller one to accomplish the planned
procedure.
A guiding catheter with a larger diameter does not always
provide stronger backup. If there is plaque at the ostium, an
8-Fr guiding catheter is likely to damage the plaque, whereas
a 7-Fr catheter may be passed through the ostium and engaged
just beyond it, providing much stronger backup. If an 8-Fr
guiding catheter is used in such circumstances, a catheter
with side holes may be a good choice. Although a catheter
with side holes can effectively prevent coronary ischemia, it
cannot prevent ostial injury. In fact, using such a catheter may
rather increase the risk of ostial injury because you cannot
recognize that the tip has become wedged. This is why I question the selection of an 8-Fr guiding catheter with side holes
for the purpose of obtaining stronger backup.
In contrast to an 8-Fr guiding catheter, a catheter with a
smaller diameter (as small as possible) is less likely to cause
ostial injury. When deeply seated, a smaller guiding catheter
can often provide stronger local backup as it ensures coaxiality between devices and the target vessel.
However, performing PCI for CTO usually requires a
combination of techniques, so one has to consider the optimal
size of the guiding catheter to ensure success with all of the
techniques that might be used. Antegrade PCI for CTO sometimes requires guidance by intravascular ultrasound (IVUS).
If the guidewire exit port of the IVUS catheter is trapped
by an implanted stent, a 7-Fr (or larger) guiding catheter is
sometimes required to successfully remove the IVUS catheter
together with the aid of a balloon without causing stent deformation (see Column 15 [page 174]). This is why I always use
a 7-Fr guiding catheter from the start of PCI.
In female patients, I introduce a 7-Fr guiding catheter via the
femoral artery rather than the radial artery because of its size. If
a femoral artery is not available for catheterization, I choose the
trans-brachial (TB) approach in female patients. When performing retrograde PCI, a 6-Fr guiding catheter may be sufcient, so
the TR approach can be used even in female patients.
The TR and TB approaches should be avoided when
performing PCI for occlusion of the left circumex artery
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021
K. Mitsudo, Non-Pushing PCI Techniques, https://doi.org/10.1007/978-981-15-7043-8_1
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1 Mitsudo’s PCI Techniques forCTO
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(LCX) because one of the two optimal orthogonal projections for viewing LCX lesions can be a projection from
deep left anterior oblique (LAO) to the left outer (LO). In
such projections, the brachium often overlaps the heart,
which results in poor imaging conditions and prevents
assessment of the anatomy of the target vessel.
Note that I always use the left radial artery for the
TR approach. When choosing the TB approach, I always
use the right brachial artery because a sheath introducer
placed in the left brachial artery is too far from the
interventionalist.
1.1.1.2 Fluoroscopic Angles forBiplane
Cineangiography andPuncture Sites
As I will explain later, it is essential to view the target lesion
in two orthogonal projections that provide the longest possible images of the longitudinal axis of the target vessel. I
take care to exclude the arms and other interfering objects,
particularly from lateral views.
In some cases, good images of the LCX (particularly its
middle and distal segments) can only be obtained with the
patient’s arms raised above the head. Accordingly, the TR
and TB approaches should be avoided when performing PCI
for LCX lesions.
Sometimes, the biradial approach is employed in male
patients, and the left radial/right brachial approach is used
in female patients. However, these approaches are incompatible with the arm-raising posture and require the patient’s
left arm to be raised anteriorly, which severely limits the
choice of uoroscopic angles. Therefore, I only use these
approaches in exceptional cases.
1.1.1.3 Inuence ofSevere Tortuosity and/or
Stenosis
Both the TB and TR approaches should be avoided if diagnostic catheterization shows severe tortuosity of the innominate (brachiocephalic) artery, because such vascular anatomy
may preclude these approaches. Conversely, the TF approach
may occasionally require cannulation through more tortuous
vessels that can make it difcult to manipulate the guiding
catheter. In such cases, the TB or TR approach is a better
choice.
Table 1.1 Optimum guiding catheter size
Antegrade approach
Target
coronary
artery Male Female Male Female
TF
approach
LMT 7 7 – 7 – 7 7(6) 7 – 7 (6) 7
LAD 7 7 – 7 – 7 7(6) 7 – 7 (6) 7
LCX 7 – – 7 – – 7(6) – – 7 – –
RCA 7 7 – 7 – 7 7(6) 7 – 7 (6) 7
“(6)”: a 6-Fr catheter can also be used
“—”: this approach should be avoided whenever possible
TR
approach
TB
approach
TF
approach
TR
approach
TB
approach
Retrograde approach
TF
approach
TR
approach
TB
approach
TF
approach
TR
approach
TB
approach
ab c
1.2 Sheath
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1.2 Sheath
Whether I perform antegrade or retrograde PCI, I use a thickwalled, non-kinking sheath with a length of 40 or 45cm for
the TF approach. Although there are also long non-kinking
sheaths that are exible enough to easily follow a tortuous
vessel, I do not use sheaths of this type (Fig.1.1).
If a exible sheath is introduced into a tortuous vessel,
the guiding catheter must subsequently be advanced while
straightening the sheath that has conformed to the tortuosities of the vessel, causing considerable friction between the
sheath and catheter so that there is no benet of previously
introducing the sheath. If the guiding catheter is advanced
further in an attempt to stabilize its tip, the tortuous region
tends to become even more tortuous. This can result in failure to acquire backup and signicantly impair manipulability of the guiding catheter (Fig.1.1b).
On the other hand, a stiff, thick-walled, non-kinking
sheath can pass through a tortuous vessel while somewhat
straightening it and will remain almost straight itself. If a
guiding catheter is advanced through such a straight sheath,
there is less friction between the sheath and catheter. Thus,
the catheter remains manipulable, and good backup can be
acquired (Fig.1.1c).
When using a stiff sheath, there is concern about the risks
associated with vascular stress due to the “accordion” phenomenon. To reduce the risk of this phenomenon, I recommend repeated to-and-fro movement of the sheath, rather
than simply continuing to push it forward until it advances
smoothly. Specically, I recommend pulling the sheath back
and pushing it forward over a 2- to 3-cm distance after it has
been advanced completely. This helps to stabilize the sheath
within the vessel.
If a sheath cannot advance smoothly within a very tortuous vessel, do not advance it forcibly, but instead replace the
guidewire with an extra stiff wire (Fig.1.2). Alternatively,
make a small curve at the top of the sheath (Fig.1.3), and
then push the sheath forward while rotating it. Using these
methods, it is often possible to advance a sheath past the
blockage in a vessel.
When performing TF interventions, including procedures
for CTO, I always use a sheath with a length of 40 or 45cm.
I think that a long sheath has several advantages, while there
are no disadvantages or inconveniences. One of the advantages of a long sheath is the small gaps between the guidewire, dilator, and sheath during advancement of the sheath
(Fig.1.4). Although I often use an inner sheath catheter to
reduce the gap between the guidewire and the guiding catheter, using a long sheath makes the gaps between devices
even smaller.
Therefore, there is a very low risk of injuring the vessel wall or scraping off plaque to cause embolism while a
long sheath is being advanced. When exchanging a guiding
catheter, the new catheter can be advanced smoothly beyond
the abdominal aorta through a long sheath, and the inner
sheath catheter protects the vessel wall while the catheter is
advanced into the thoracic aorta.
Cholesterol embolization syndrome (blue toe syndrome)
is an infrequent, but potentially fatal, complication of
PCI.This complication became less frequent after I started
to use an inner sheath catheter for PCI, and it is even less
frequent since I started to use long sheaths.
Fig. 1.1 Long non-kinking sheath. (a) Tortuous right iliofemoral
artery. (b) A long, exible, non-kinking sheath follows the tortuous vessel easily, but develops the same tortuosities as the vessel. To advance a
guiding catheter, the sheath has to be straightened, which generates friction between catheter and sheath. (c) A stiff, thick-walled sheath passes
through a tortuous vessel while straightening it somewhat and maintaining a linear shape. Therefore, there is less friction when a guiding
catheter is advanced through the sheath. A sheath of this type is much
more useful than the exible sheath shown in b, both for advancing the
guiding catheter and for obtaining sufcient backup
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1 Mitsudo’s PCI Techniques forCTO
Fig. 1.2 Method of advancing a sheath through a very tortuous ilio-
femoral artery—abdominal aorta. (a) When the guidewire in the sheath
kit is advanced through a tortuous vessel, it passes along the inner curvature of each bend. (b) A stiff sheath cannot be advanced smoothly
through such a vessel because its tip deviates in the outward direction at
a
b
each curve, generating considerable friction with the vessel wall. (c) A
guidewire with a stiff shaft can be used to straighten the tortuous vessel.
(d) If a sheath is advanced along the stiff guidewire, outward deviation
at the curves becomes smaller, and friction with the vessel wall is
reduced. Thus, the sheath can often be advanced smoothly
a
b
c
Fig. 1.4 Gaps between the sheath, dilator, and guidewire. The gaps
shown in a are obviously smaller than those in b or c (gaps between a
Fig. 1.3 Photograph of a sheath with a slightly bent tip. A sheath with
a slightly bent tip can easily follow a tortuous vessel and can straighten
the vessel after the tip has passed through it
7-Fr guiding catheter and a 5-Fr inner sheath catheter or between a 5-Fr
diagnostic catheter and a guidewire, respectively)
ab
1.3 Guiding Catheter
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1.3 Guiding Catheter
1.3.1 Selection oftheGuiding Catheter
My method of selecting guiding catheters is very simple.
For the left coronary artery (LCA), either the Launcher
SL or EBU is my rst choice, while the BriteTip AL or
Launcher SAL is my rst choice for the right coronary
artery (RCA).
I have specied the manufacturers and model numbers
of the guiding catheters above because I have good reasons
for limiting my selection. Multiple manufacturers currently
produce guiding catheters with identical model numbers, but
the catheters of these different manufacturers show different levels of performance (even if they have the same model
number), and many products fail to deliver the expected performance or rather cause problems for the operator.
1.3.1.1 Amplatz-Type Catheter fortheRCA
I choose an Amplatz-type guiding catheter for PCI of
the RCA, and not a Judkins-type catheter, for the reasons
described below.
Since the Judkins guiding catheter only has a single curve,
it permits more linear manipulation of the guidewire toward
the RCA ostium compared with the Amplatz guiding catheter,
which has two curves. However, this is not a decisive point.
The Judkins catheter only provides weak backup, which is
clearly noticeable when attempting to advance a balloon
or another device over a guidewire that has been advanced
through the guiding catheter. If the RCA ostium is oriented
downward and not involved by a lesion, a deeply seated
Judkins catheter can provide some backup. Alternatively,
it should be pushed forward while being rotated clockwise
to create an Amplatz-like shape. Adequate backup may be
obtained if its shaft is pushed against the contralateral wall of
the sinus of Valsalva. Anchoring the catheter is another way
of obtaining better backup.
However, if you choose the Amplatz guiding catheter in
this situation, you can obtain enough backup by engaging
the guiding catheter in the RCA and keeping its shaft contralateral to the sinus of Valsalva. The greatest advantage of
the Amplatz catheter is the ability to obtain backup from the
entire sinus of Valsalva, including the contralateral wall and
the aortic valve.
You may also use the Judkins catheter if there is a side
branch available to anchor it. If there is no side branch, several
problems will arise when performing PCI with the Judkins
catheter, especially for occlusive ostial lesions. As shown in
Fig.1.5, the tip of the Judkins catheter may be blocked by the
occlusion, and it may even be impossible to perform imag-
ing of the target vessel. In the LAO view, the RCA ostium
and the tip of the guiding catheter appear to be coaxial with
each other, but it is difcult to achieve true coaxiality. If the
target vessel has a large enough diameter from the ostium to
a more peripheral site, coaxiality can be achieved by advancing the catheter tip a little further to that site. However, this
is difcult with most ostial lesions. The right anterior oblique
(RAO) and AP views will clearly show that the guiding catheter is not in a coaxial position, with the Judkins catheter tip
generally being deviated rightward from the orientation of the
RCA ostium. In this situation, it is impossible to advance the
guidewire toward the entry point coaxially with the occluded
vessel. Lack of coaxiality also reduces manipulability of the
guidewire. When the guidewire is advanced forcibly, the
guiding catheter may be pushed back or may become disengaged due to insufcient backup (Fig.
1.6). Antegrade PCI
for CTO of the RCA ostium will never be successful with the
Judkins catheter, except in some lucky cases such as when the
occlusion is tapered.
If an Amplatz-type guiding catheter of an appropriate size
is used, its tip can be disengaged and placed just beneath
the RCA ostium (Fig.
1.7). Namely, it is possible to stably
maintain the catheter tip coaxial with the RCA ostium and at
the optimum distance. If a guidewire is advanced through a
guiding catheter positioned in this way, it can be manipulated
easily and is more likely to enter the true lumen at the site
of occlusion.
Fig. 1.5 Possible outcomes with the Judkins guiding catheter. If the tip
of the catheter is located close to the entry point, as is usual when performing PCI for CTO of the RCA ostium, the penetration site and direction of the guidewire are dependent on the position and orientation of
the catheter tip. A favorable outcome can be obtained if the tip of the
catheter and the occluded vessel are completely coaxial with each other
and if the catheter tip is oriented toward the desired entry point (a).
However, the catheter tip is usually not coaxial with the occluded vessel, and its orientation is slightly deviated from the entry point (b)
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a
b
c
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1 Mitsudo’s PCI Techniques forCTO
Fig. 1.6 Possible outcomes with the Judkins guiding catheter. If a
Judkins right-type guiding catheter is used during PCI for CTO of the
RCA ostium, the catheter may initially be coaxial with the occluded
Fig. 1.7 Using an Amplatz left-type guiding catheter (AL) during PCI
for CTO of the RCA ostium. If an Amplatz left-type guiding catheter is
engaged, the pressure waveform will be damped, and tip injection will
not provide sufcient information about the vascular anatomy and
rather has the potential to injure the ostium. Engagement of this type of
guiding catheter is risky because it makes both guidewire manipulation
and angiography impossible (a). However, an AL-type guiding catheter
vessel (a). However, when a guidewire is advanced slightly through the
guiding catheter (b), the catheter often becomes disengaged due to
insufcient backup (c)
with a specic shape can readily be disengaged when pushed slightly
(b). A guidewire can be manipulated freely through the guiding catheter
from a site slightly away from the entry point if the tip of the catheter is
maintained just beneath the RCA ostium (c). With the guiding catheter
in this position, the pressure waveform is also normalized and safe and
high-quality angiography becomes possible
1.3.1.2 Tips When Using anAmplatz Left-Type
Guiding Catheter fortheRCA
Shape oftheCatheter Tip
Guiding catheters that are made by different manufacturers,
even those with an identical model number (e.g., “AL1”),
vary considerably regarding their performance and the shape
of the curve at the tip. Figure1.8 shows photographs of representative “AL 1” short-tipped guiding catheters made by
three manufacturers (Group A). The tips have curves with
different shapes. I use guiding catheters in Group A (e.g.,
BriteTip, Launcher, and Hyperion), which commonly have a
“deep” second curve unlike those in Group B.
The advantages of having a deep second curve are illustrated in Fig. 1.9 (a–c). When a guiding catheter with a
deep second curve is pushed forward, its tip spontaneously
backs away from the RCA ostium while being maintained
in a coaxial position to the ostium. When such a catheter is
pulled back, its tip goes forward and enters the RCA.The
former movement of the catheter tip (spontaneously back-
ing away) makes it less likely that the RCA ostium will be
injured and good backup is generated by pushing the shaft
against the contralateral wall of the sinus of Valsalva. In
contrast, a guiding catheter with a “shallow” second curve
enters the RCA when pushed forward and disengages from
the ostium when pulled back (Fig.1.9 (d–f)). During both
movements, the shaft of the catheter remains unstable
(“oating”) within the sinus of Valsalva, rather than generating good backup. Since such a catheter has to be pushed
forward to play its role, it must have side holes. This inevitably increases the volume of contrast medium that is used
as well as placing stress on the ostium, thereby increasing
the risk of ostial injury.
Although I generally recommend using “AL 1” shorttipped guiding catheters for PCI of the RCA, I have always
only employed the catheters in Group A for the abovementioned reasons. Figures 1.10, 1.11, 1.12, and 1.13
(Figs.1.10–1.13) show representative coronary angiograms
(CAGs) of CTOs of the RCA that were treated by PCI using
guiding catheters from Group A or Group B.
Group A Group B
Amplatz Left Guiding Catherer
1.3 Guiding Catheter
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BriteTip Launcher Hyperion Group B
7
Deep
Fig. 1.8 Tip curves of short-tipped Amplatz left (AL 1 ST) guiding
catheters produced by different manufacturers until 2015. Group A:
BriteTip AL 1 ST, Launcher SAL 1, and Hyperion AL 1 ST.Group B:
“AL 1 ST” guiding catheters produced by many manufacturers (Mach1
Fig. 1.9 Tip behavior of
guiding catheters with
different second curves. The
upper row shows a guiding
catheter from Group A.After
initial engagement to the
optimal depth (a), advancing
the catheter results in it
becoming less deeply engaged
(b), while pulling back leads
to deeper engagement (c). The
lower row shows a guiding
catheter from Group B.Initial
optimal position (d). When
the catheter is advanced, its
tip tends to go deeper into the
RCA (e). When the catheter is
pulled back, its tip disengages
from the ostium (f)
Group A
Good for engagement Push in the GC Pull back the GC
Group B
Deep
abc
def
Deep
Deep
AL 1 ST is shown here). Group A guiding catheters are characterized by
a greater distance between the tip and the bottom of the second curve (a
“deep” second curve), while Group B catheters have a “shallow” second curve
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1 Mitsudo’s PCI Techniques forCTO
Fig. 1.10 PCI for CTO of the RCA using guiding catheters from
Groups A and B: Initial use of a Group B catheter. PCI for CTO of the
RCA was initiated with an AL 1 ST guiding catheter like a Group B
type. (a) Because it had short rst and second curves, the catheter could
be easily manipulated within the sinus of Valsalva and was engaged in
the RCA.Ease of achieving engagement is the greatest advantage of
Fig. 1.11 PCI for CTO of the RCA using a Group B
guiding catheter. When the guidewire is advanced
toward the CTO, the guiding catheter is pushed back,
and it can easily become disengaged because the
posterior side of the catheter shaft is not supported
by the contralateral wall of the sinus of Valsalva, as
seen in the cusp images
guiding catheters with such tip characteristics. (b) The tip of the catheter is coaxial with the RCA ostium and appears to be engaged well.
However, the posterior side of the second curve of the catheter tip is
oating within the sinus of Valsalva (arrows). The dotted curves indicate valve cusps
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