Retrograde Approach for RCA CTO Lesion: Reverse CART Technique

- Operator : Seung-Whan Lee

Retrograde Approach for RCA CTO Lesion: Reverse CART Technique
- Operator: Seung-Whan Lee, MD
Case Presentation
A 49 year-old male was admitted for the evaluation of Coronary CT angiography abnormality. The coronary angiography was performed, which reveled significant stenosis LM to proximal LAD, and CTO lesion proximal RCA. Then, LM to proximal LAD lesion was already stented. The left ventricular systolic function was normal without regional wall motion abnormalities, we decided to re-vascularize his right coronary artery.
Baseline Coronary Angiogram
  1. The coronary angiography showed total occlusion at proximal RCA with grade 3 collateral flow from distal LAD. ( Movie 1, Movie 2)
  2. The left coronary angiogram showed previous stent of LM to proximal LAD was found to be patent.
Procedure
Right coronary artery was engaged a 7 Fr AL1 guiding catheter and left coronary artery was positioned with a 7 Fr XB 3.5 guiding catheter through the bi-femoral approach. At first, we tried anterograde approach using Fielder XT-A, Gaia second with Corsair 135cm catheter, but it was not successful. ( Movie 3) After that, we tried retrograde approach using SUOH, Gaia second, Fielder XT-R wire with Corsair 150cm catheter. ( Movie 4) After careful subintimal tracking of the retrograde guidewire directed to the tip of antegrade guidewire, the subintimal space was dilated with PCI balloons (IKAZUCHI 2.5 x 15mm and TREK 3.5 x 15mm) in antegrade direction. ( Movie 5) After the true lumen of the anterograde was confirmed by IVUS, a stent (Xience Alpine 4.0 x 28 mm) was implanted to secure the lumen for the reverse CART. (Figure 1) Finally, successful advancement of retrograde guidewire into the space dilated with drug-eluting stent and the retrograde wire was externalized into RCA guiding catheter. (Figure 2) Thereafter, the CTO lesion was treated with usual IVUS-guided coronary intervention methods. Four Xience Alpine (2.75 x 28, 3.0 x 38, 4.0 x 38mm) stent was sequentially deployed from distal to proximal with some overlap. (Figure 3) The final angiogram showed well positioned and expanded stent with good distal run-off flow. ( Movie 6, Movie 7) We attached final IVUS images. ( Movie 8)

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