Experts "Live" CTO Workshop 2014 25th Septemper 2014 in Madrid, Spain

1. Alfredo R. Galassi MD, FESC, FACC, FSCAI
Director of Cardiac Catheterization and
Interventional Cardiology Unit
Department of Medical Sciences and Pediatrics
Division of Cardiology, Cannizzaro Hospital,
University of Catania, Italy
A Likely “Simple” Reverse CART

2. CASE SUMMARY
Clinical Presentation
Exertional angina (CCSC III) and dyspnea (NYHA II)
Patient: Z-M, male, 59 yrs
Risk Factors
Hypertension Diabetes type I Ex-smoker
Coronary Angiography
Proximal RCA CTO
Non-invasive Testing
2D Echo: mild hypokinesia of inferior wall , EF 55%

3. Coronary Angiography
Target lesion: RCA

4. First Septal
Sion
Asahi Intecc
Corsair
Asahi Intecc
00:42

5. First Septal (different branch)
Sion
Asahi Intecc
Corsair
Asahi Intecc
00:22

6. Progression of Corsair
Sion
Asahi Intecc
Corsair
Asahi Intecc
Laborious progression of Corsair (calcifications)
01:11

7. Exchanging retrograde wire
Fielder XT-R
Asahi Intecc
Corsair
Asahi Intecc
00:18

8. Exchanging retrograde wire
Retrograde wire:
Gaia 1 st
Asahi Intecc
Antegrade wire:
Fielder XT-R
Asahi Intecc
00:17

9. Exchanging retrograde wire
Retrograde wire:
Gaia 2 nd
Asahi Intecc
Antegrade wire:
Fielder XT-R
Asahi Intecc
Advancement of Finecross over Fielder XT-R
01:26

10. Retrograde wire:
Gaia 2 nd
Asahi Intecc
Antegrade wire:
Fielder XT-A
Asahi Intecc
Removal of Finecross (Nanto technique)
Balloon advancement/inflation
Exchanging antegrade wire
00:38

11. Exchanging retrograde wire
Retrograde wire:
Miracle 6
Asahi Intecc
Antegrade wire:
Fielder XT-A
Asahi Intecc
00:44

12. Exchanging microcatheter
Retrograde wire:
RG 3
Asahi Intecc
Antegrade wire:
Fielder XT-A
Asahi Intecc
Corsair fatigue
00:32

13. Retrograde wire:
Fielder FC
Asahi Intec
Antegrade wire:
Fielder XT-A
Asahi Intec
Reverse Knuckle Technique?
00:26

14. Balloon advancement
Retrograde wire:
Fielder FC
Asahi Intec
Antegrade wire:
Fielder XT-A
Asahi Intec
00:42

15. Exchanging retrograde wire
Retrograde wire:
Pilot 150
Abbott Vascular
Antegrade wire:
Fielder XT-A
Asahi Intecc
01:50

16. Antegrade wire:
Fielder XT-A
Asahi Intecc
Two different subintimal plans
Retrograde wire:
Pilot 150
Abbott Vascular
01:18

17. Two different subintimal plans
Antegrade wire:
Fielder XT-A
Asahi Intec
Retrograde wire:
Pilot 150
Abbott Vascular
Antegrade IVUS ?
00:34

18. Reverse CART Attempt
Antegrade wire:
Fielder XT-A
Asahi Intecc
Retrograde wire:
Pilot 150
Abbott Vascular
Advancement of the balloon distally
00:14

19. Reverse CART Attempt
Antegrade wire:
Fielder XT-A
Asahi Intecc
Retrograde wire:
Pilot 150
Abbott Vascular
Better back up with AL1 guiding catheter
Distal balloon inflations
01:36

20. More Distal Reverse CART Attempt
Antegrade wire:
Fielder XT-A
Asahi Intecc
Retrograde wire:
Pilot 150
Abbott Vascular
01:51

21. Externalization
Externalization
RG 3
Asahi Intecc

22. 4 everolimus eluting stents of
3.0 x 28 mm
Stents Implantation

23. Final Result

24. Take Home Messages
- Reverse CART is a reliable retrograde technique to
achieve CTO revascularization success
- Antegrade IVUS might be a useful and helpful tool
- A Crossboss and stingray approach might be a useful
tool
- A more distal reverse CART using stiff polymeric
wires to dissect antegradely, might be an alternative
option in case of two different subintimal plans very
apart from each other, especially when occurring in a
tortuous segment of the artery