Slides

Treatment of Proximal RCA CTO Lesion Using Retrograde Approach "Reverse CART Technique"

- Operator : Etsuo Tsuchikane

Treatment of Proximal RCA CTO Lesion Using Retrograde Approach "Reverse CART Technique"
- Operator: Etsuo Tsuchikane, MD
Case Presentation
This 65-year old gentleman was admitted to our hospital for evaluation of chest pain on exertion and shortness of breathing. His coronary risk factors were hypertension, dyslipidemia and smoking. He had a history of unstable angina which led him to receive bare metal stent implantation at left circumflex artery (LCX) in 1996. The echocardiography showed severe LV dysfunction (EF=32%) with multiple regional wall motion abnormalities.
Baseline Coronary Angiography
The left coronary angiogram showed total occlusion at juxta-proximal site of previous stent at LCX and tight narrowing at middle portion of left anterior descending artery (LAD) ( Movie 1, Movie 2). The proximal portion of right coronary artery (RCA) also revealed a chronic total occlusion (CTO) ( Movie 3, Movie 4).
Procedure
A 7 Fr AL1 and XB 3.5 guiding catheter was engaged into the right and left coronary ostium, respectively. Initially, the antegrade approach of RCA CTO lesion was attempted with Fielder XTA 0.014 inch-190cm PCI-guidewire supported by 1.8Fr Finecross microcathter. After several attempts and identifying the subintimal tracking of the guidewire (Figure 1), we changed our strategy to the retrograde approach using one distal septal collateral channel. After stenting the stenotic lesion at mLAD ( Movie 5, Movie 6), the 0.014 inch-180cm Sion blue guidewire was passed through LAD to distal septal branch supported by 2.6 Fr Corsair 0.014 inch-150cm microcatheter (Figure 2, Figure 3). After careful subintimal tracking of the retrograde guidewire directed to the tip of antegrade guidewire (Figure 4), the subintimal space was dilated with small PCI balloons (Lacrosse 1.3 x 10mm and Maverick 2.5 x 15mm) in antegrade direction (Figure 5, Figure 6). After successful advancement of retrograde guidewire into the space dilated with antegrade balloon (reverse CART technique), the retrograde wire was externalized into RCA guiding catheter. Thereafter, the CTO lesion was treated with usual IVUS-guided coronary intervention methods. After predilating the lesion with a Maverick 2.5 x 15mm balloon, Promus Premier 3.0 x 38 mm and 3.5 x 32mm stent was sequentially deployed from distal to proximal fashion with some overlap (Figure 7). The final angiogram showed well positioned and expanded stent with good distal run-off flow ( Movie 7, Movie 8).

Comments

  • Bing Liu 2014-07-29 Congratulation，clear strategy and excellent result. You said, after the retrograde wire externalized into RCA GC, the IVUS-guided PCI was used. You meaned the antrgrade wire crossed cto segment in true lumen finally and the sequential des inplanted all in trul lumen? If that was correct, reverse cart was not used in stentd inplantation. Can you give some details? Thanks
  • Hyun Woo Park 2014-07-31 The antegrade wire did not cross CTO segment. So we tried to advance wire retrograde approach. But retrograde wire did not cross CTO segment by true lumen. We decied to perform 'Reverse CART'. For ease of advance to antegrade subinitimal space, we dilated antegrade space with small PCI balloons. After the retrograde wire externalized into RCA GC, we checked IVUS. The IVUS finding was not all true lumen.

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