Transcript
Page 1: BTK crossing technique for the uncrossable” lesion crossing technique for the “uncrossable” lesion Tatsuya Nakama MD. Miyazaki Medical Association Hospital, Miyazaki, Japan

BTK crossing technique for the

“uncrossable” lesion

Tatsuya Nakama MD.

Miyazaki Medical Association Hospital,

Miyazaki, Japan

Page 2: BTK crossing technique for the uncrossable” lesion crossing technique for the “uncrossable” lesion Tatsuya Nakama MD. Miyazaki Medical Association Hospital, Miyazaki, Japan

Speaker name: Tatsuya Nakama MD.

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I have the following potential conflicts of interest to report:

Consulting: Boston Scientific Japan, Century Medical Inc.

Employment in industry: None

Stockholder of a healthcare company: None

Owner of a healthcare company: None

Other(s): Honoraria recieved from

Abbot Vascular, Asahi Intecc., Boston Scientific, COOK, Cordis

Cardinal Health, Goodman, KANEKA, Lifeline, Medikit, Medtronic,

Orbus Neichi, Terumo,

Disclosure

Page 3: BTK crossing technique for the uncrossable” lesion crossing technique for the “uncrossable” lesion Tatsuya Nakama MD. Miyazaki Medical Association Hospital, Miyazaki, Japan

Definition of

“Uncrossable”

・GW crossing?

・Device crossing?

Page 4: BTK crossing technique for the uncrossable” lesion crossing technique for the “uncrossable” lesion Tatsuya Nakama MD. Miyazaki Medical Association Hospital, Miyazaki, Japan

Strategies of GW crossing1. Antegrade approach

1-1: Intraluminal approach

・Japanese art: 0.014-inch GW

1-2: Subintimal approach (loop technique)

・Hydro-dynamic boost (SUICA)

・Micro-knuckle

2. Retrograde approach

2-1: Distal puncture

2-2: Trans-collateral or pedal

Page 5: BTK crossing technique for the uncrossable” lesion crossing technique for the “uncrossable” lesion Tatsuya Nakama MD. Miyazaki Medical Association Hospital, Miyazaki, Japan

Severely Calcified lesions

Challenges in

“Device Crossing”

Page 6: BTK crossing technique for the uncrossable” lesion crossing technique for the “uncrossable” lesion Tatsuya Nakama MD. Miyazaki Medical Association Hospital, Miyazaki, Japan

Case overview

Page 7: BTK crossing technique for the uncrossable” lesion crossing technique for the “uncrossable” lesion Tatsuya Nakama MD. Miyazaki Medical Association Hospital, Miyazaki, Japan

60s male, CLI

60s MaleType 2 DM, HDRutherford 6

Wifi CS 4・FPA CTO・BTK CTO

Page 8: BTK crossing technique for the uncrossable” lesion crossing technique for the “uncrossable” lesion Tatsuya Nakama MD. Miyazaki Medical Association Hospital, Miyazaki, Japan

Initial angiogram in 2nd EVT

Page 9: BTK crossing technique for the uncrossable” lesion crossing technique for the “uncrossable” lesion Tatsuya Nakama MD. Miyazaki Medical Association Hospital, Miyazaki, Japan

Initial angiogram of BTK lesion

Page 10: BTK crossing technique for the uncrossable” lesion crossing technique for the “uncrossable” lesion Tatsuya Nakama MD. Miyazaki Medical Association Hospital, Miyazaki, Japan

Treatment strategy

<First challenge>Severely calcified

TPT revasc.→ Necessary

<Next challenge>

Tibiopedal revasc.→ If it possible

Page 11: BTK crossing technique for the uncrossable” lesion crossing technique for the “uncrossable” lesion Tatsuya Nakama MD. Miyazaki Medical Association Hospital, Miyazaki, Japan

TPT revascularization

Page 12: BTK crossing technique for the uncrossable” lesion crossing technique for the “uncrossable” lesion Tatsuya Nakama MD. Miyazaki Medical Association Hospital, Miyazaki, Japan

Challenging situation…

NC balloon Cutting balloon

Page 13: BTK crossing technique for the uncrossable” lesion crossing technique for the “uncrossable” lesion Tatsuya Nakama MD. Miyazaki Medical Association Hospital, Miyazaki, Japan

Scoring balloon

Scoring balloon

Page 14: BTK crossing technique for the uncrossable” lesion crossing technique for the “uncrossable” lesion Tatsuya Nakama MD. Miyazaki Medical Association Hospital, Miyazaki, Japan

What should we do???

Page 15: BTK crossing technique for the uncrossable” lesion crossing technique for the “uncrossable” lesion Tatsuya Nakama MD. Miyazaki Medical Association Hospital, Miyazaki, Japan

Front cult debulking devices…

These devices are not available in Japan

Jetstream

Rotablator

Diamondback

Page 16: BTK crossing technique for the uncrossable” lesion crossing technique for the “uncrossable” lesion Tatsuya Nakama MD. Miyazaki Medical Association Hospital, Miyazaki, Japan

Amazing final solution

Brockenbrough Needle

Page 17: BTK crossing technique for the uncrossable” lesion crossing technique for the “uncrossable” lesion Tatsuya Nakama MD. Miyazaki Medical Association Hospital, Miyazaki, Japan

Challenging procedure….

Page 18: BTK crossing technique for the uncrossable” lesion crossing technique for the “uncrossable” lesion Tatsuya Nakama MD. Miyazaki Medical Association Hospital, Miyazaki, Japan

It seemed dangerous…

Ready….

Page 19: BTK crossing technique for the uncrossable” lesion crossing technique for the “uncrossable” lesion Tatsuya Nakama MD. Miyazaki Medical Association Hospital, Miyazaki, Japan

Attack with Brockenbrough needle!!

Go!!

Page 20: BTK crossing technique for the uncrossable” lesion crossing technique for the “uncrossable” lesion Tatsuya Nakama MD. Miyazaki Medical Association Hospital, Miyazaki, Japan

Angiogram after debulking

Page 21: BTK crossing technique for the uncrossable” lesion crossing technique for the “uncrossable” lesion Tatsuya Nakama MD. Miyazaki Medical Association Hospital, Miyazaki, Japan

Additional POBA with NC balloon

Page 22: BTK crossing technique for the uncrossable” lesion crossing technique for the “uncrossable” lesion Tatsuya Nakama MD. Miyazaki Medical Association Hospital, Miyazaki, Japan

Angiogram after POBA

Page 23: BTK crossing technique for the uncrossable” lesion crossing technique for the “uncrossable” lesion Tatsuya Nakama MD. Miyazaki Medical Association Hospital, Miyazaki, Japan

Additional PTA revascularization

Antegrade go down to the outside

Page 24: BTK crossing technique for the uncrossable” lesion crossing technique for the “uncrossable” lesion Tatsuya Nakama MD. Miyazaki Medical Association Hospital, Miyazaki, Japan

Intentional (bi-directional)subintimal approach

Avoid the calcified plaque(Bi-directional approach may be required)

Page 25: BTK crossing technique for the uncrossable” lesion crossing technique for the “uncrossable” lesion Tatsuya Nakama MD. Miyazaki Medical Association Hospital, Miyazaki, Japan

Challenging plantar artery puncture

Second GW go up to the true lumen

Page 26: BTK crossing technique for the uncrossable” lesion crossing technique for the “uncrossable” lesion Tatsuya Nakama MD. Miyazaki Medical Association Hospital, Miyazaki, Japan

Subintimal angioplasty & Rendezvous

Successful Rendezvous

Astato XS 9-12Retrograde subintimal approach

with Knuckled Regalia XS 1.0

Page 27: BTK crossing technique for the uncrossable” lesion crossing technique for the “uncrossable” lesion Tatsuya Nakama MD. Miyazaki Medical Association Hospital, Miyazaki, Japan

POBA to PTA & pedal

Page 28: BTK crossing technique for the uncrossable” lesion crossing technique for the “uncrossable” lesion Tatsuya Nakama MD. Miyazaki Medical Association Hospital, Miyazaki, Japan

Final angiogram

Page 29: BTK crossing technique for the uncrossable” lesion crossing technique for the “uncrossable” lesion Tatsuya Nakama MD. Miyazaki Medical Association Hospital, Miyazaki, Japan

Clinical course

TMA was demonstrated for infection control

Good clinical course

Page 30: BTK crossing technique for the uncrossable” lesion crossing technique for the “uncrossable” lesion Tatsuya Nakama MD. Miyazaki Medical Association Hospital, Miyazaki, Japan

Low-profile 1.5mm or less B/C POBA 2.0mm long

Microcatheter (1.6 to 2.0-Fr)

Pass the lesionNOT Pass the lesion

NOT Pass the lesion

Use OFF LABEL devices Crosser (BARD)

Rotablator (Boston)

Brockenbrough needle

BAD FORM technique

Procedure with Monorail type support catheter

Intentional sub-approach

(avoid Ca plaque)

Strategy for uncrossable lesion

Page 31: BTK crossing technique for the uncrossable” lesion crossing technique for the “uncrossable” lesion Tatsuya Nakama MD. Miyazaki Medical Association Hospital, Miyazaki, Japan

Several Devices & techniques

Front-cut debulkingNOT AVAILABLE

BAD FORM

PIERCE

Low-profiledballoon

Extension guide

CrosserOFF label

Brockenbrough needle

Page 32: BTK crossing technique for the uncrossable” lesion crossing technique for the “uncrossable” lesion Tatsuya Nakama MD. Miyazaki Medical Association Hospital, Miyazaki, Japan

Uncrossable cases were observed

Page 33: BTK crossing technique for the uncrossable” lesion crossing technique for the “uncrossable” lesion Tatsuya Nakama MD. Miyazaki Medical Association Hospital, Miyazaki, Japan

(Deep venous arterialization)

may be final option

Page 34: BTK crossing technique for the uncrossable” lesion crossing technique for the “uncrossable” lesion Tatsuya Nakama MD. Miyazaki Medical Association Hospital, Miyazaki, Japan

Concept of DVAIn flow

BTK & BTAdisease

Insufficient perfusion

Capillary

Failed revascularization

Tissue perfusion may improve

DVA :Deep venous arterialization

Page 35: BTK crossing technique for the uncrossable” lesion crossing technique for the “uncrossable” lesion Tatsuya Nakama MD. Miyazaki Medical Association Hospital, Miyazaki, Japan

Our 1st case of DVA

Page 36: BTK crossing technique for the uncrossable” lesion crossing technique for the “uncrossable” lesion Tatsuya Nakama MD. Miyazaki Medical Association Hospital, Miyazaki, Japan

Control angiogram

Page 37: BTK crossing technique for the uncrossable” lesion crossing technique for the “uncrossable” lesion Tatsuya Nakama MD. Miyazaki Medical Association Hospital, Miyazaki, Japan

Arterial revascularization was failed

Failed POBA PIERCE technique Balloon ruptureGW crossing

Page 38: BTK crossing technique for the uncrossable” lesion crossing technique for the “uncrossable” lesion Tatsuya Nakama MD. Miyazaki Medical Association Hospital, Miyazaki, Japan
Page 39: BTK crossing technique for the uncrossable” lesion crossing technique for the “uncrossable” lesion Tatsuya Nakama MD. Miyazaki Medical Association Hospital, Miyazaki, Japan

Angiogram after the procedure

Page 40: BTK crossing technique for the uncrossable” lesion crossing technique for the “uncrossable” lesion Tatsuya Nakama MD. Miyazaki Medical Association Hospital, Miyazaki, Japan

Clinical course (immediately after DVA)

Page 41: BTK crossing technique for the uncrossable” lesion crossing technique for the “uncrossable” lesion Tatsuya Nakama MD. Miyazaki Medical Association Hospital, Miyazaki, Japan

Conclusion

BTK intervention is always challenging

We have to continue dedicated effortto make a future options & evidences

for “Untreatable” patients

Page 42: BTK crossing technique for the uncrossable” lesion crossing technique for the “uncrossable” lesion Tatsuya Nakama MD. Miyazaki Medical Association Hospital, Miyazaki, Japan

BTK crossing technique for the

“uncrossable” lesion

Tatsuya Nakama MD.

Miyazaki Medical Association Hospital,

Miyazaki, Japan


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