CCT 2014 organized by J-WINC :00~10:00 kobe International Exhibition Hall 2F Room 8 1

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1 CCT 2014 organized by J-WINC :00~10:00 kobe International Exhibition Hall 2F Room 8 1

2 Part 1: Greetings Good morning, everybody. Thank you for attending this live demonstration. We are at Saiseikai Yokohamashi Eastern Hospital. I m Masatsugu Nakano, one of the cardiologists at this hospital. I ll be performing the procedure today. I m glad to have this opportunity. Dr. Araki, another cardiologist at this hospital, will assist me. I d like to share this case with you and explain about the procedure. I d like to say thank you to Dr. Honye, today s chairperson, for her great support. 2

Part 2: Case Presentation today s case. Let me introduce The patient is a male in his seventies. In 2007, the patient was transferred to our hospital due to AMI, and a PCI was carried out on his RCA.

3 Part 2: Case Presentation today s case. Let me introduce The patient is a male in his seventies. In 2007, the patient was transferred to our hospital due to AMI, and a PCI was carried out on his RCA. In 2008, a PCI was performed to treat the residual stenosis from the LMT to LAD. Today s target lesion is an RCA. For the RCA, a TAXUS stent was implanted at segment one and a Cypher stent at segments two and three. The patient complained of chest pain. We performed a catheter test, the first time he had undergone one in three years. There were no significant lesions in the LCA. However, compared with previous data, there was an apparent progression observed at the ostium of the RCA. A TAXUS stent was previously implanted at RCA segment one, but did not reach the ostium. It s difficult to define whether it can be called a peri-stent stenosis or a new lesion. The RCA ostium stenosis is our target for today. Risk factors are hypertension, hyperlipidemia, and smoking. There is no evidence of diabetes mellitus. There is no chronic renal impairment and creatinine level is within the normal limits. 3

4 This is the case for today. I m glad to share it with you. 4

5 Part 3: Systems We will perform 6Fr TRI, approaching from the right transradial artery. Today s system: The guiding catheter is a JR 3.5, and the wire we will use is a Route. Now I ll start the procedure. To reduce radiation exposure, we try to take as few images as possible. We often store images rather than taking images or DSAs. We consider where staff members, nurses and medical engineers are standing and try not to use X-rays when they are close to us. 5

Part 7: IVUS A B C I m going to check the ostium lesion using the IVUS. Since Dr.

The IVUS used is an OptiCross TM produced by Boston Scientific.

Honye came to our hospital to instruct, she recommended that we use them. I m going to pull back from around here, the distal lesion of the RCA.

6 Part 7: IVUS A B C I m going to check the ostium lesion using the IVUS. Since Dr. Honye is here as a chairperson today, she will give us her educated opinion about the images. The IVUS used is an OptiCross TM produced by Boston Scientific. We use IVUS for 80 to 90 percent of our PCIs, mostly using the IVUS produced by Boston Scientific. When Dr. Honye came to our hospital to instruct, she recommended that we use them. I m going to pull back from around here, the distal lesion of the RCA. Are you ready? Please begin pulling back. As you can see, the distal lesion of the RCA exhibits calcification. The calcification is superficial. The diameter is about 3 mm (C). The TAXUS Express TM stent was implanted around here. You can see TAXUS Express TM stent over the calcified lesion (B). As you can see, there is circumferential calcification. The eccentric plaque is observed at the proximal of the stent. 6

7 The calcification is not as severe as expected. Stop. Save the record, please. Let s see the osmium lesion again. Please start recording. Here is the ostium lesion. There is calcification at the ostium (A). At this hospital, whenever we do a stent for an RCA ostium, marking is done through the IVUS. We place IVUS at the position of the stent and take an angiographic image, which shows us the correct position. In this case, I put IVUS at the osmium then take and image, which shows us the osmium. 7

Part 5: Predilatation The pre-dilatation should be administered because of calcification. What about the balloon size for pre-dilatation? What is the vessel diameter of the IVUS? The diameter is 3.

Does anyone have any suggestions as to what kind of balloon should be used? Is there any recommended type of balloon?

8 Part 5: Predilatation The pre-dilatation should be administered because of calcification. What about the balloon size for pre-dilatation? What is the vessel diameter of the IVUS? The diameter is 3.0 mm. I believe 3.0 mm is fine. I ll dilate using a 3.0 mm balloon first. If that doesn t dilate the ostium sufficiently, then post-dilatation will be performed as well. Does anyone have any suggestions as to what kind of balloon should be used? Is there any recommended type of balloon? Since calcification was observed, Scoreflex TM or a cutting balloon may be appropriate. Are there any other recommendations? If calcification is present, you may consider using a scoring balloon or a cutting balloon. I don t have any particular preference, but today I m going to use a scoring balloon. Could you give me a 3.0 mm Lacrosse NSE, please? 8

9 I ll perform predilatation using the scoring balloon first, and then insert a stent. Next, I ll dilate the balloon, which is slightly protruding outside the ostium. Inflate. To 14 atm, please. Please store the image. Now deflate. As you can see, the ostium dilatation was insufficient. I m going to slightly dislodge the guiding catheter and add more pressure. Inflate to 14 atm, the rated pressure. Deflate. The ostium has now dilated sufficiently. Please store the image. I ll also take an image of this. 9

Part 6: Stenting I m going to insert a stent here. Next we need to determine the best stent for an RCA ostium lesion. I ve decided to use a drug-eluting stent, but there are several DESs available.

10 Part 6: Stenting I m going to insert a stent here. Next we need to determine the best stent for an RCA ostium lesion. I ve decided to use a drug-eluting stent, but there are several DESs available. Which DES should I choose? Does anyone have any recommendations for a stent for the RCA ostium? In my opinion, a XIENCE stent tends to be difficult to position properly. I m therefore not confident enough to place a XIENCE stent precisely in a particular location, especially for an ostium lesion. The next possibility is a PROMUS stent. It is easier to position properly. However, the edge of this stent is fragile and I m concerned about stent deformation when we place it at the ostium.. The remaining selections are a NOBORI TM and an Integrity TM. Now let s consider the hinge motion. In this lesion, there is a subtle hinge motion that may be hard to see. 10

11 The Integrity TM stent is designed to deal with this hinge motion and has better flexibility. Flexibility is one of the important factors when choosing a stent for RCA ostium. That is why I use an Integrity TM stent. What is the vessel size by the IVUS? It s 3.0 mm. Could you show the IVUS marking picture? Now I m going to insert a stent. I m going to use a Resolute Integrity TM. Now we will inflate to 9 atm. Now deflate. Next, I slightly dislodge the guiding catheter. Next, we inflate up to 9 atm. Now deflate. One more time. Inflate. Deflate. I m repositioning the balloon to protrude partially outside the stent. Inflate to 16 atm. Now deflate. Part of the balloon is still partially outside the stent. I ll inflate again. Inflate to 16 atm. Deflate. I ll take an image. I ll check the IVUS again. 11

Part 7: Post Dilatation Let s look at the IVUS. Please start pulling back. This is the distal area. You can see the calcification. However, the lumen is secured. This is the Integrity TM stent.

12 Part 7: Post Dilatation Let s look at the IVUS. Please start pulling back. This is the distal area. You can see the calcification. However, the lumen is secured. This is the Integrity TM stent. I m afraid the stent was not sufficiently expanded. This is the ostium. Is it expanded enough? The Integrity TM stent was placed to protrude in front of the ostium by two struts. Stopping the IVUS. Let s do it manually. The stent is placed so as to protrude slightly outside the ostium, but the stent was also not sufficiently expanded at the ostium. I think post-dilatation is necessary. The post-dilatation balloon should be a 3.25 mm high-pressure balloon. I will do post-dilatation for the ostium as well as thedistal area. 12

13 The vessel diameter (the EEM diameter) was measured at 3.25 mm by the IVUS. What do you think is the best balloon for the post-dilatation? Of course, you will choose a high-pressure balloon, but for the high-pressure balloon there are several options. It may be a 3.0, 3.25 or 3.5 mm balloon. Because I m quite cautious, I chose a 3.25 mm balloon. What is the nominal pressure? It s 12 atm. How about the rated pressure? 20 atm. Let s inflate. 20 atm. Deflate. Inflate. 20 atm. Deflate. Inflate. Here, I ll do a longer inflation, for twenty seconds. Deflate. Inflate again, up to the rated pressure. One minute, please. Deflate. I m going take an image. I ll perform IVUS. 13

Part 8: Final Image Since the ostium was not expanded sufficiently, I applied high pressure usinga 3.25 mm high-pressure balloon. It seems to be well expanded now. Let s look at the IVUS again.

14 Part 8: Final Image Since the ostium was not expanded sufficiently, I applied high pressure usinga 3.25 mm high-pressure balloon. It seems to be well expanded now. Let s look at the IVUS again. Could you start pulling back? Yes, it s well expanded. This is near the ostium lesion. The stent was placed, with two struts protruding outside the ostium. I consider slightly outside the ostium is better. The protruding struts don t disturb a guiding catheter engagement. Recently, I ve heard that one of the authorities in this field mentioned that restenosis of ostium of the RCA is caused by deviation of the stent. I ve been wondering if it s true or not,but it may be true because of its hinge motion. In this case, placing the stent outside the ostium bytwo struts may produce better outcomes. Are you ready? Let s take the final image. This is the final image. Do you agree that this procedure is finished? 14

Part 8: Thank you I ve successfully carried out the procedure today, placing a stent at the RCA ostium lesion. We chose a relatively simple case for this live demonstration.

I m actually wondering how to handle this discussion on the stage on the day. Anyway, I hope this live video demonstration will promote discussion.

15 Part 8: Thank you I ve successfully carried out the procedure today, placing a stent at the RCA ostium lesion. We chose a relatively simple case for this live demonstration. I understand that you will discuss the case in English as you watch it. During the procedure, I spoke a lot in Japanese. I m actually wondering how to handle this discussion on the stage on the day. Anyway, I hope this live video demonstration will promote discussion. I would like to extend my gratitude to Dr. Honye and other members who assisted in the preparation of this demonstration. I would also like to extend my gratitude to Dr. Tsukahara, who chose me for this role. I d like to extend my gratitude to everybody. 15

16 Part 10: Messages from Ms. Tani 16

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