Retrograde approach "Reverse CART technique" in pLAD CTO blesion

- Operator : Etsuo Tsuchikane

Retrograde approach "Reverse CART technique" in pLAD CTO blesion
- Operator: Etsuo Tsuchikane, MD
A 59 year-old man was admitted to hospital for treatment of CAD. He had a history of MI and had undergone successful stenting for proximal, distal RCA and RI lesion, but failed PCI for pLAD CTO lesion at 2011.

He had coronary risk factors such as dyslipidemia and current smoking history with 40 pack-years. As a non-invasive function test, thallium SPECT was done and showed partial reversible large sized perfusion defect of LAD territory. Treadmill test was negative. The trans-thoracic echocardiography showed akinesia of LAD territory with normal LV systolic function (EF=58%).
Baseline Coronary Angiogram
1. A left coronary angiogram showed total occlusion of pLAD with collateral flow from to PDA and patent stent at RI.( Movie 1, Movie 2)
2. A right coronary angiogram showed patent stent at pRCA and dRCA.
Left coronary artery was cannulated with a 7 Fr XB 3.5 guiding catheter by right femoral artery and right coronary artery was positioned with 8 Fr AL1 guiding by left femoral artery. A SION 0.014 inch 175cm guidewire with a Corsair¢ē 0.014 inch 2.6 Fr -135cm microcatheter was approached to retrograde pathway to LAD. ( Movie 3) Due to tortuosity, the guidewire was changed to XT-R 0.014 inch-190cm. An XT-R 0.014 inch 190cm guidewire with a Corsair¢ē 0.014 inch 2.6 Fr -135cm microcatheter was successfully advanced to proximal LAD by retrograde approach. (Figure 1) By using Extension wire 0.014 inch 150cm, we exchanged XT-R 0.014 inch guidewire to SION 0.014 inch 175cm guidewire. By using Ryujin 2.5 X 15mm balloon, we advanced Corsair microcatheter to LAD. A Fielder FC 0.014 inch 180cm guidewire passed distal LAD by antegrade approach. At this point, the reverse-CART technique was performed and a Ryujin 2.5 X 15mm balloon was introduced in an antegrade manner. ( Movie 4) The 0.014 inch RG3 Blue one 330cm guidewire was inserted from the left guiding catheter to the right guiding catheter and it formed a wire loop (retrograde wire externalization). From the guidewire tip outside the right sheath, predilatation with the Ryujin 2.5 X 15mm balloon was performed.(Figure 2) After the IVUS examination, three drug-eluting stent were deployed (Xience V 3.0 X 12mm at proximal LAD, Xience prime 2.5 X 33mm, and Xience V 2.5 X 23mm in the distal LAD, sequentially) The final angiogram showed successful revascularization at the LAD CTO lesion.(Figure 3, Figure 4)


  • Joao Alexandre Farjalla 2011-07-22 Whas is cost effective against CABG since the begining?
  • Jong-Young Lee 2011-07-23 The patient received primary PCI with multiple stenting in another hospital. The patient visited our center for CTO intervention, only. So in our center, we could not provide the chance of bypass surgery. As a final result, the total cost was almost same between PCI and CABG. Originally, we heard the patient refused initial bypass surgery at the beginning from operator of the initial hospital. After procedure, we have managed with cardiac rehabilitation and optimal medical therapy.
  • Vijay Shah 2011-07-31 The description of the procedure is confusing .was the Fielder FC wire used to cross the distal LAD antegradely or retrogradely thru the Corsair?Was the RG3blue 330cm wire introduced thru the Rt.AL1 guiding catheter to the Lt.EB3.5 guiding catheter forming a wire loop?.....dr v t shah,mumbai,india.
  • carlos fernandez pereira 2011-08-04 Nice case and very clear explanation.I don¢„t see any confused issue.Regarding cost effective study: it is not the question ,at this point we are discussing about procedure,not public health.Also we must take in to account the patient willing about treatment modality.
  • Jong-Young Lee 2011-08-04 Thank you for your interest for this case, Dr Vijay Shah. The Fielder FC wire was tried to cross the occluded segment antegradely, using the guidance of retrograde wire but failed. So we used the reverse CART technique using antegrade ballooning, and then fortunately the retrograde-SION wire could cross the occluded segment. After cross the lesion with retrograde-Corsair microcather, we changed to the RG3 330cm long wire. The RG3 330cm long wire could pass from the Rt.guiding cathter to the Lt.guiding catheter, called as retrograde wire externalization. Using the externalized RG3 wire at the Lt. side, we performed the procedure step by step. The similar procedure techniques for more cases were also listed in this website.
  • Jong-Young Lee 2011-08-04 Thank you for your clear and great comment, Dr. carlos fernandez pereira. Totally I agree your opinion. I appreciate for your sincere interest, again.
  • tangqiang 2012-01-30 how you retrace the RG3 Blue one 330cm guidewire after pci was done?antegradely or retrogradely?if antegrade,dose it hurt the donor vessal?thank you.

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