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Figure 1. Concept of parallel wiring technique. DX1 : 1st diagonal branch; LAO: Left anterior oblique; RAO: Right anterior oblique.
(Figure omitted. See article PDF.)
Figure 2. Parallel wiring technique. A patient with bypass graft failure. The proximal was almost straight and the occlusion length was not very long (A & B) . After the first wire entered into the subintimal space (C) , the second wire, a tapered stiff wire, was easily and successfully led into the distal true channel under the marker of the first wire (D & E) . Final angiographic result after stenting (F & G) .
(Figure omitted. See article PDF.)
Figure 3. Anchoring technique. Proximal right coronary artery (RCA) was completely blocked with bridging collaterals (A) . A Judkins-type catheter was used to prevent damage to the RCA ostium. However, presence of tight plaque in the chronic total occlusion causes unstable back-up support of the guiding catheter during wire handling. Hence, the wire could not be advanced intentionally
(B) . A 2.5-mm balloon was then inserted and inflated with a low pressure in the conus branch to stabilize the guiding catheter (C) . With the use of this anchoring balloon, the wire control was improved, and thus the occlusion was successfully negotiated (D) . Final angiographic result after stenting (E).
(Figure omitted. See article PDF.)
Figure 4. Other methods of anchoring technique. (A) When a stiff wire failed to penetrate a proximal fibrous cap, an over-the-wire balloon was inflated proximal to the occlusion as a support catheter for wire handling. The inflated balloon provides extra back-up force for the wire tip to penetrate the proximal cap.
(B) Anchor wiring into a proximal branch also provides a better back-up force.
(Figure omitted. See article PDF.)
Figure 5. Intravascular ultrasound guidance. Although the left anterior descending artery was completely blocked around mid-portion, it was hard to identify the entrance of a chronic total occlusion (CTO) despite the contralateral injection being performed (A & B) . An intravascular ultrasound (IVUS) catheter was then inserted into the septal branch (C) . The IVUS image easily identified the CTO entrance (D & E) . This IVUS examination was also effective when using a stiff wire to penetrate the tight proximal fibrous cap (F)