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138 PART IV Wires Technique
LAO 60°RAO 30°
LAO 60°
RAO 30°
t
degrees clockwise
(1) Thewireisdivided into shaft and tip sections
CTO in the mid RCA
Initial wring screen
Guidewire
(3)“The object (shaft or tip) is alwaysinfront(behind)onthe next imageafterrotationifthe object is in thesame(opposite)direction
as the rotationaldirectionof the X-raydetector.”,and simplied,“thesame is in frontand theoppositeisbehind”.
Shaft: Thedirectionofthe shaftin relationtothe target is assessed
Then it is determined whether thedirection of the shaft on theinitial
monitorscreen is in the same rotational directionas the detector
in aneutral direction,orthe opposite direction.
(4) Z axis information on the shaft and tip is applied on the screen after rotation, and a 3D image is constructed.
Vessel
Shaft
Tip
Target
RAO 30°
Opposite
Shaft (at the left
of the target)
Perpendicular screen
LAO 60°
Direction of detector
rotation (to the right)
On theZaxisin this screen,
the shaft is behind thetarget
Behind
(2)An imagesinwhich an operator views from thedetector is created.
In this example, thedetectorismoved to theright from therst direction
(RAO30º) to thenext direction(LAO 60º).
Direction of the
detector rotation
RAO 30°
Tip: It is simply determined whether the direction of the apex of the tip
on the initial monitor screen is in the same rotational direction as the
detector, in a neutral direction, or the opposite direction.
Z axis information on the shaft and tip is applied on the
rotated screen (LAO 60°), and 3D mental image is created.
(to the right)
Same
Tip(directing to the right)
Direction of detector
rotation (to the right)
LAO 60°
On theZaxisin this screen,
the tipisdirectedtothe fron
Front
Initial wiring screen Perpendicular (90 degrees) screen
Shaft
Tip
Behind
Front
Vessel
Target
RAO 30 °
Based on the 3D mental image thus created, the wire(torque) is rotated 45
and pin-point penetration is conducted
Behind
Front
LAO 60 °
Clockwise
45°
pin-point
penetration
Figure 16.5 How to construct a 3D image from 2 orthogonal fluoroscopic observations using the 3D imaging rule.
monitor screen. In short, the operator has the same view
as the detector. Once this image is created, movement of
the detector from left to right and from up to down is
translated into the image on the monitor also moving
from left to right and from up to down. (3) Then a 3D
image is constructed using the 3D image rule. To assess
the positional relationship of the guidewire shaft to the
target, its depth (Z axis) is determined. It is determined
whether the optional relationship of the guidewire shaft
to the target on the screen is in the same rotational
direction as the detector, in a neutral direction, or the
opposite direction. For example, Figure 16.5 shows the
guidewire located to the left of the target on the monitor
in the 30-degree RAO view. To obtain the 60-degree
LAO view (perpendicular to the previous view), the
detector should be moved to the right (to the right side of
the monitor). In accordance with the 3D imaging rule,
after rotation of the detector to the 60-degree LAO view,
the shaft is positioned behind the target on the screen.
The same rule can be applied for the tip of the guidewire.
It is determined whether the direction of the tip of the
guidewire on the initial monitor screen is in the same
rotational direction as the detector, in a neutral direction,
or the opposite direction. In Figure 16.5, the tip is
CHAPTER 16 3D Wiring Methods in CTO PCI 139
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Figure 16.6 One more illustration: How to construct a 3D image from 2 orthogonal fluoroscopic observations using the
3D imaging rule.
directed to the right on the monitor in the RAO
30-degree view. Next, the detector is moved to the right
(to the right side of the monitor) for observation in the
LAO 60-degree view. Since the direction of the tip is
directed to the right and is in the same rotational
direction as the detector, the apex of the tip is facing
toward the operator on the monitor in the 60-degree
LAO view. (4) Finally, using the monitor image in the
60-degree LAO view, 3D image is created from the
above-mentioned Z axis information on the wire shaft
and tip. The guidewire is rotated carefully, and pin-point
penetration is conducted.
This method is explained again in Figure 16.6 [4].
The guidewire is manipulated while viewing the
initial screen. As can be seen in Figure 16.6, when the
detector is moved to the right, the first screen shows
that the shaft of the guidewire positioned at the left
side (reverse direction) of the target and the tip is
directed to the right (same direction). Consequently,
in the next 9 patterns of the perpendicular screen, the
shaft of the guidewire (Z axis) is located behind the
target and the wire tip is located in front of it (Figure
16.6A). If the detector is moved to the left, the Z axis
always becomes opposite (Figure 16.6B).
Note that the targets of 3D wiring include not only
the final target but also the sequential targets on the
ideal virtual route from 1 cm before the final target,
which is the concept of “sequential targets” (Figure
16.7B) [4]. That is, 3D wiring is the method of tracing
the ideal route imaged from virtual or visualized
vessel walls while recognizing the rotational direction
of a guidewire using the 3D imaging rule to converge
the guidewire tip to the final target (Figure 16.7A,
16.7B) [4].
Training of angiography-based 3D wiring
using rotational ETOSS model
Angiography-based 3D wiring requires training with a
CTO model that can be observed from two orthogonal
directions, such as the Rotational ETOSS model (Asahi
Intecc Co., Ltd.). We show videos demonstrating 2D
wiring and 3D wiring using the 3D imaging rule using
the Rotational ETOSS model (Figure 16.8) [11]. Please
watch our videos in reference 11 (doi: 10.1007/s12928022-00861-3) and check whether you can understand
our manipulation of the 3D wiring using the 3D
imaging rule at least in your brain.
Differences in angiography-based 3D
wiring between the experimental model
and clinical practice
A prerequisite for conducting the 3D wiring technique in clinical practice is that it can first be performed in an experimental model. However, even
when reproducible wiring can be conducted in an
experimental model, CTO lesions vary in clinical
practice and there are many occasions in which it is
not appropriate to attempt the angiography-based 3D
wiring. It is important to understand which lesions
are difficult to the angiography-based 3D wiring
(Figure 16.9) and to utilize 2D or 3D wiring on caseby-case basis as appropriate.
140 PART IV Wires Technique
A.
Observations from two orthogonal
directions 90 degrees apart
Guidewire
Shaft
Tip
Vessel
Target
RAO 30º
LAO 60º
B.
Virtual vessel
1
Shaft
Tip
1 cm
Ideal
route
1
Shaft
Tip
2
3
2
4
Mentally constructed 3D image
using the 3D imaging rule
Clockwise 45º
RAO 30º
Figure 16.7 Concept of sequential targets during the angiography-based 3D wiring.
Magnied image of CTO lesion
LAO 60º
40 mm
Final target
Sequential target
Final target; Exit, island or the route imagined from sites of calcication, etc.
Direction of guidewire advancement
Angiographic direction of observation on cross-sectional images
3
4
Video1
5
6
5
6
7
7
6 mm
Demonstration of 2D wiring-1
Final target of inner diameter 0.4 mm
Monitor screen from
the rotational camera
Rotational camera
CTO lesion
7F guide catheter
Figure 16.8 Video presentation of angiography-based 2D and 3D wiring in CTO-PCI. Okamura., 2022 / Springer Nature.
Clinical indications for the angiographybased 3D wiring in the antegrade or
retrograde approach
The angiography-based 3D wring technique should
be used whenever possible in the antegrade approach.
Candidate targets include an island of contrast
medium in the CTO lesion or a visible exit site and
CTO lesions where the course of the vessel can be
estimated from coronary artery calcification or from
a previous stent in the case of in-stent re-occlusion
(Figure 16.10A). When the retrograde approach is
employed, a retrograde wire is positioned as the target
and antegrade 3D wiring is conducted. The 3D wiring
is generally difficult in retrograde guidewire manipulations since the torque of the retrograde wire cannot
be maintained. Only when the reverse controlled
antegrade and retrograde subintimal tracking (CART)
technique is performed, an antegrade balloon will be
punctured by a retrograde guidewire using the 3D
wiring (Figure 16.10B).
Video2
Demonstration of 2D wiring-2
Video3
Demonstration of 3D wiring
CHAPTER 16 3D Wiring Methods in CTO PCI 141
2. No landmark
3. Torque of the wire cannot be maintained
n
4.
1. The wire cannot be advanced by pushing
A. Antegrade approach
B. Retrograde approach
balloon
Exit or island
Retro-wire
Center line of the vessel
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CTO
Misalignment between the guiding catheter and the axis of the lesion
CTO
Figure 16.9
CTO lesions difficult to the angiography-based 3D wiring technique in clinical practice.
Exit or island
CTO
Obscure exit site
CTO
Calcication
In-stent restenosis
If the vessel wall is identied,
3D wiring to trace the center
line is possible (central wiring).
Obscure CTO route
Retro-wire
Calcication / sever
tortuosity of the lesio
CTO
5. Lesion with a false lumen
Sub-intima
Reverse-CART
Ante-balloon
<1cm
Figure 16.10 Targets of 3D wiring technique during the antegrade and retrograde approaches.
Techniques for effective use of the
angiography-based 3D wiring technique
in clinical practice
1) Maintain back-up support for the guidewire,
select a guidewire with sufficient tip load initially,
and form only the first curve with 45 degrees and
1.0 mm
The main guidewire manipulation of 3D wiring is to
advance the guidewire after the direction of the tip to
the target, therefore enough back-up support against
the guidewire should be maintained. The guide catheter should be at least 7Fr, the microcatheter should
be a Corsair (Asahi Intecc Co., Ltd.) to provide enough
back-up support and anchoring in a lateral branch
should be performed as needed (Figure 16.11A).
When a tapered soft wire such as a XT-R wire (Asahi
Intecc Co., Ltd.) cannot be advanced any further and
the distance to the target is about 1 cm, a Conquest
(Confianza) 12g wire with the pre-shape of 45 degrees
and 1 mm (Asahi Intecc Co., Ltd.) should be chosen. If
a guidewire with an insufficient tip load is selected, it
cannot be advanced just by pushing and it will have to
be rotated, which becomes 2D wiring instead of 3D
wiring. After that, if the guidewire is changed to a
<1cm
142 PART IV Wires Technique
mm.
s
A. Enough back -
Anchoring
CTO
Long anti-kinking sheath
Figure 16.11 Techniques for effective use of the 3D wiring technique.
up
for guidewire
Microcrater with an
enough back-up force
CTO stiff wire
≥7F Guide catheter
Conquest-12g, the CTO tissue has become too fragile
to keep the pivot-like movement, making accurate
manipulation difficult (Figure 16.11B).
The vessel size of coronary CTO lesions is usually
3–4 mm, and only a small 1st-curve of 1 mm and 45
degrees is formed on a CTO stiff wire (Figure 16.11C).
For Conquest (Confianza) wires, 1 mm and 45-degree
pre-shape types are available from Asahi Intecc, therefore use this Conquest pre-shape type.
2) Observe from two orthogonal directions 90
degrees apart as possible as you can
For accurate manipulation of the guidewire under
angiographic guidance, it is important to perform observation in 2 optimum directions located perpendicular
B. Earlystepupto
without hesitation
Tapered (0.010 inch) soft wires
CTO intermediate stiff wires
Ultimate bros 3, Gladius,
3D
or GAIA families
CTO stiff wires whose tip load is ≥ 9g
Conanza 9g,12g, 8-20g
GAIA Next 3, 4 (only soft plaque)
(at 90 degrees) to each other whenever possible.
However, the direction of the orthogonal observation
has been determined based on the operators’ experience.
After we began to use computed tomography (CT) True
View (Phillips, Amsterdam, the Netherlands) to find out
the orthogonal observational direction, we noticed that
the direction that was thought to be the direction of the
orthogonal observation was incorrect in about half of the
sites of coronary arteries.
Figure 16.12 shows perpendicular pairs of detector
directions at each site of the coronary tree that can be
assessed by angiography, as analyzed with CT True
View. As the coronary artery model commonly used
in Japanese catheterization laboratories and the actual
CTO stiffwires
Non-3D>3D
C. Small rst-curve
Form a 45 degree-curve
with a length of ≤ 1.0
Pre-shape Conquest wire
should be used.
GAIA 2nd
Conquest-pro 9g
Bending length : 0.8 mm
•
•Angulation : 40°
1 mm
Figure 16.12 The direction of the orthogonal observation of the X ray detector at each coronary site.
CHAPTER 16 3D Wiring Methods in CTO PCI 143
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coronary artery model made by a 3D printer have different coronary artery running, the directions of the
orthogonal observation at Seg3, 6, 11, 13 are particularly different from those based on experience. In general, Seg3 is observed from LAO to anteroposterior
(AP) caudal views, Seg6 is observed from LAO to
RAO at cranial views and Seg11–13 are observed from
LAO to RAO at caudal views. However, Seg3 runs
horizontally from left to right, and the direction of the
orthogonal observation is cranial to caudal at
45-degree LAO view, Seg6 runs horizontally in the
front left direction and the direction of the orthogonal
observation is cranial to caudal at 45-degree LAO
view, and the direction of the orthogonal observation
at Seg11–13 is from 30-degree AP caudal to 45-degree
LAO view.
Clinical outcomes of the angiographybased 3D wiring technique
We started clinical application of the angiographybased 3D wiring technique at Sakurabashi Wanatabe
hospital (Osaka, Japan) in May 2014. We conducted a
retrospective analysis of 181 consecutive subjects who
received PCI at our hospital from 2014 until 2017 to
assess the results of treating CTO before and after
adoption of the 3D wiring technique [4]. Patients in
whom the CTO was successfully crossed by a tapered
soft wire alone were excluded. Among the remaining
patients, 69 were assigned to the 3D wiring group (3D
group) and 68 patients treated before we adopted the
new technique were assigned to the non-3D wiring
group (Non-3D group) (Figure 16.13A).
In both groups, approximately 30% of patients were
treated by the retrograde approach. The success rate
of the antegrade approach was significantly higher in
the 3D wiring group (Figure 16.13B). In the primary
antegrade cases, the first antegrade approach time
was significantly shorter in the 3D wiring group than
the non-3D wiring group (42
± 29 vs. 30 ± 16 min,
respectively; p <0.01) and the success rate of only the
antegrade approach was increased from 55% (n = 33
of 60) in the non-3D wiring group to 69% (n = 40 of
58) in the 3D wiring group, but the difference was
not significant (Figure 16.13C). Regarding the guidewires successfully crossing the CTO lesions in the
primary antegrade cases, the percentage of Conquest
(Confianza) family was slightly higher in the 3D wiring group compared with the non-3D wiring group
(75% vs. 55%, respectively; p < 0.063) (Figure 16.13D).
In contrast to the experimental study, we often faced
the clinical cases in which the angiography-based 3D
wiring was not effective due to the advancement of
guidewires into the subintimal spaces.
AO-IVUS-based 3D wiring technique
for intraplaque tracking
Establishment of the real-time IVUSguided 3D wiring method
Over the past decade, we have established a number of
devices and methodologies for standardization of
IVUS-guided wiring as the key to maximizing the
accuracy of guidewire manipulation in CTO PCI. In
2012, we developed Navifocus WR, the first CTOspecific IVUS, with a small profile and a short distance
from the tip to the transducer [1, 2]. We selected
Navifocus WR IVUS-guided wiring as much as possible instead of parallel wiring and tried to accurately
Figure 16.13 Retrospective single-center study of angiography-based 3D wiring.
144 PART IV Wires Technique
B.
When boththe shaft andtipofthe guidewire are
n
manipulate the guidewires under the IVUS observation, but we felt that the success rate could likely not be
greatly improved. However, observation of the
movement of the guidewires in the CTO lesions indicated the importance of 3D manipulation of the guidewires. Therefore, in 2014, we devised the 3D imaging
rule and established angiography-based 3D wiring as
described above [3, 4]. However, the angiographybased 3D wiring method is no longer effective when
the target is not visible or when the guidewire enters the
subintimal lumen [4]. To overcome these situations, we
have tried to establish the real-time IVUS-based 3D
wiring. We devised “the tip detection method” and
developed “AO-IVUS” (Terumo Corp.), which is an
upgraded version of Navifocus WR with an added pullback transducer system [5]. As AO-IVUS was launched
in Japan in 2019, AO-IVUS-based 3D wiring using the
tip detection method made it possible to manipulate
the guidewire in real time with accurate rotation of the
guidewire within a few degrees inside CTO lesions.
The concept of the tip detection method
and the new CTO-specific IVUS (AO-IVUS)
for the tip detection method
In an IVUS-guided wiring method in CTO PCI, the
IVUS catheter is advanced through the first wire
which has already entered a subintimal space. Then
the second wire is navigated to be passed through the
intraplaque route by the IVUS observation from the
subintimal space. As well as the angiography-based
3D wiring, it is necessary to recognize the rotational
direction of the guidewire (torque) in IVUS-based 3D
wiring. When only the shaft of the guidewire is
observed, the rotational direction and angle for
maneuvering the guidewire toward the target cannot
be determined (Figure 16.14A) [5]. However, when
both the shaft and tip (tip and its direction) of the
guidewire are observed, the rotational direction and
angle for maneuvering the guidewire toward the
target can be determined (Figure 16.14B) [5].
There are two methods of IVUS-guided 3D wiring.
One is the conventional method, which is named
“fusion method” that fuses the IVUS image and fluorographic image using Navifocus WR or Eagle-eye
IVUS (Phillips) (non-pull back & short tip IVUS) in
the operator’s brain (Figure 16.15A) [2], and the other
is the direct visualization only by the IVUS observation using AO-IVUS (pull back & short tip IVUS),
which is named “tip detection method” (Figure
16.15B) [5]. The IVUS guided wiring performed
outside of Japan has been still up to the fusion method.
But the fusion method is complicated and inaccurate
because the tip cannot be visualized in real time with
IVUS and is an alternative method when the tip detection method cannot be performed in Japan. AO-IVUS
and the tip detection method are needed to change the
IVUS guide wiring from last resort to standard.
We describe the tip detection method that enables
real-time, high-precision IVUS guided wiring.
Observing the guidewire by IVUS has meant observation of the guidewire shaft but not the tip. However,
for the 3D wiring methods, information on both the
wire shaft and tip is essential. Because the CTO lesion
(intraplaque, distal lumen, etc.) can be also visualized
by IVUS, by observing not only the shaft but also the
tip by IVUS, 3D wiring can be performed only by
IVUS-based 3D wiring
IVUS transducer
True lumen (Intraplaque)
CTO
The IVUStransducer is positionedjustbeyondthe
transition site fromtrue lumentosubintimalspace.
A. When onlythe shaft of the guidewire is observed,the rotational
direction andangle for maneuveringthe guidewire toward the target
cannot be determined.
IVUS image
Figure 16.14 For IVUS guided 3D wiring, it is necessary to observe the tip as well as the shaft.
IVUS observation from a subintimal space
Subintimal space
Shaft
IVUS
Subintima
Target
True lumen
observed,the rotational direction and angle for
Subintima
True lumen
maneuvering the guide wire to ward the target ca
be determined.
IVUSimages
IVUS
Rotate the guidewire
counterclockwise after
pulling it backslightly
Rotate the guidewire
clockwise afterpulling
it backslightly.
CHAPTER 16 3D Wiring Methods in CTO PCI 145
A. Fusion method using Navifocus WR or Eagle Eye IVUS
IVU
Direct visual construction of 3D
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(non-pull back & short tip IVUS)
Shaft
Intraplaque
Exit lumen
Shaft
Angiographic image
IVUS
Tip
Tip
Microcatheter
CTO
euqalpartnI
2
S
-wire
amitnibuS
st
-wire
1
Figure 16.15 A. Fusion method using Navifocus WR or Eagle Eye IVUS (non-pull back & short tip IVUS). B. Tip detection
method using AnteOwl WR IVUS (AO-IVUS; pull back & short tip IVUS).
IVUS image
Subintima
IVUS
Operator views the cine
from this direction.
nd
Mentally constructed 3D image
from angiographic and IVUS images
OTCfonemultixE
Slight pull -back and counterclockwise
IVUS information. This method is the tip detection
method. By moving the AO-IVUS transducer back
and forth around 3 mm between the apex of the tip
and the transition point of the tip to the shaft, the tip
and its direction can be clearly visualized. The shaft is
seen as a bright spot with an echo shadow and the tip
is a slightly faint line from base to apex (Figure
16.16A) [5]. By moving the transducer back and forth
around from the target to the tip area, the 3D image
(AO-IVUS; pull back & short tip IVUS)
IVUS images
Subintima
Shaft
Shaft
IVUS
Intraplaque
Back and forth movement of the transducer
st
1
Visually constructed 3D image only from IVUS
-wire
images using the tip detection method
Tip
Exit lumen
Clockwise rotation
Shaft
for the guidewire manipulation can be easily visualized, which becomes possible to manipulate the
guidewire as you see it (Figure 16.16B) [5].
Figure 16.17 shows the specifications of AO-IVUS
[5]. AO-IVUS was developed from a Navifocus WR
by adding a pullback function. The following 5
improvements have been made: (1) 15 cm pullback of
a 40 MHz transducer is possible; (2) the distance from
the tip to the transducer is 8 mm (a decrease of 1 mm);
Shaft
Tip
Subintima
Intraplaque
Exit lumen of CTO
B. Tip detection method using AnteOwlWRIVUS
A. Visualization of tip B. Tip detection method
AnteOwl WR-IVUS
(AO-IVUS)
CTO
Guidewire shaft
2nd-wire
Guidewire tip
Figure 16.16 Tip detection method using AnteOwl WR IVUS.
Intraplaque
Subintima
Back and forth movement of the transducer
1st-wire
IVUS images
IVUS
Shaft
Subintima
Shaft
IVUS
Tip and its direction
Intraplaque
image only from IVUS images
Counter
clockwise
Intraplaque
Subintima
146 PART IV Wires Technique
length; 15 cm
A.
A. Antegrade wire escalation
B.
Corsair bougie C. Creation of a space
D. Starting point for the
Specications
of IVUS
Navifocus WR 9mm2.6 Fr3.2 Fr26 cm 40 MHz 0 cm
AnteOwlWR 8 mm2.6 Fr3.1 Fr26 cm 40 MHz 15 cm
B.
AnteOwlWR-IVUS (AO- IVUS)
Figure 16.17 Specifications of the CTO specific IVUSs.
(3) the IVUS catheter tip is smaller and the tip marker
has been removed (it can be visualized because contrast medium has been added to the material of the
tip); (4) the coating of the Navifocus WR has been
improved (because it tended to peel off) and it now
lasts for several uses; and (5) the base of the IVUS
catheter has been made slimmer and a 7F guide catheter can now be inserted with the Corsair catheter.
Distance from
tip to transducer
Pull-back transducer system
Maximum diameter
at transducer
Maximum shaft
diameter
Second monorail lumen length; 26 cm
Maximum shaft
diameter; 3.1 Fr
Second monorail
lumen length
Pull-back
ommended because of sufficient backup support for
the CTO guidewires. Figure 16.18 shows from antegrade guidewire escalation (AWE) to the start point of
IVUS-guided wiring. When the antegrade guidewire
is advanced to around the CTO exit but cannot be
passed through the CTO lesion due to advancement
of the guidewire into the subintimal space, etc. (Figure
16.18A), move on to the IVUS-guided wiring as much
Frequency
of transducer
Distance between 1st-and 2ndmonorail lumen gap; 8 mm
Maximum diameter
at transducer; 2.6 Fr
Distance from tip to
transducer; 8 mm
as possible instead of parallel wiring. The Corsair
Interventional procedure of AO-IVUSbased 3D wiring using the tip detection
method
More than 7-Fr guide catheter should be selected for
the IVUS based wiring. As mentioned in angiography-based 3D wiring, a Corsair microcatheter is rec-
microcatheter is advanced through the guidewire
around the CTO exit to create a space for the IVUS
catheter (Figure 16.18B, 16.18C), and if the guidewire
is a tapered wire, it should be changed to a 0.014-inch
moderately stiff CTO wire to obtain good support for
advancing the IVUS catheter. Using a double-chamber
Pull -back
length
CTO
Subintima
1st-wire
Figure 16.18 Procedural flow up to IVUS-guided wiring.
Corsair microcatheter
Intraplaque
Exit lumen of CTO
for AO-IVUS
Space created by Corsair bougie
tip detection method
Microcatheter
AnteOwlIVUS
2nd-wire
1st-wire
CHAPTER 16 3D Wiring Methods in CTO PCI 147
A.
B.
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catheter, the second guidewire is then advanced and
the microcatheter (the Corsair etc.) is advanced
through this second wire, and the IVUS catheter is
advanced through the first guidewire (Figure 16.18D).
In addition, when the IVUS catheter cannot be
advanced after the Corsair’s bougie, perform balloon
dilatation with a small-diameter balloon.
The following two steps should be performed:
positional information of vascular structures (subintimal space, intraplaque, exit lumen of the CTO, etc.) is
transferred from the IVUS image to the angiographic
image; and IVUS-based 3D wiring is performed to
accurately advance the second guidewire to the exit
lumen.
First, we explain how to recognize the location of
the targets (intraplaque, exit lumen of the CTO, etc.),
which can be visualized by IVUS, on the angiographic
image using the tip detection method (Figure 16.19)
[6]. It is difficult to recognize the location of the targets, which can be visualized by IVUS, on the angiographic image (Figure 16.19A). The second guidewire
is advanced 1 cm before the transitional site of intimal
and subintimal spaces. On the angiographic image,
the apex of the tip of the second guidewire faces to the
right (Figure 16.19B-a) and is rotated clockwise to
place the apex of the tip directly facing the operator
(Figure 16.19B-a). The tip detection method is then
performed to determine the direction from which the
operator is observing the angiographic image on the
IVUS image (Figure 16.19B-b). On the IVUS image,
the apex of the tip is directed toward the 8 o’clock
position, and the operator is therefore observing the
angiographic image from the 8 o’clock position on the
IVUS image (Figure 16.19B-c-1). It is then simply
recognized that the intraplaque area and exit lumen
are located on the right side (Figure 16.19B-c-2, men-
tally created fluoroscopic image).
Next, we describe how to perform AO-IVUS-based
real-time 3D wiring [5]. The tip detection method is
performed to accurately navigate the second guidewire to the target (intraplaque, exit lumen of the CTO,
etc.). During the guidewire navigation, the tip and its
direction are always visualized by moving the IVUS
transducer back and forth at the tip part to visually
construct the 3D image of the guidewire area (Figure
16.20A). Then, the guidewire tip is accurately navigated to the target under direct visualization while the
IVUS transducer is always advanced in accordance
with the advancement of the guidewire tip (Figure
16.20B).
Demonstration of the tip detection
method in AO-based 3D wiring using the
experimental CTO model
Figure 16.21 shows the experimental CTO model for
the AO-IVUS-based 3D wiring. We used an experimental beating heart model (Terumo Corp. Odawara,
Japan). A CTO lesion 20
mm in length and 3.0 mm in
diameter was made of 5.0% agar and inserted into the
mid-right coronary artery. The target with a 0.4-mm
lumen, which can be visualized by IVUS but not by
fluorography, was placed in the distal part of the CTO
lesion. Please refer to our YouTube video (Terumo
Interventional systems; https://www.youtube.com/
watch?v=gXJV8KT9uvc) demonstrating AO-IVUSbased 3D wiring using the tip detection method (the
first operator is A. Okamura and the second operator
is H. Nagai).
Figure 16.19 How to recognize the location of the targets (intraplaque, exit lumen of the CTO, etc.).
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