This document discusses techniques for crossing chronic total occlusions during percutaneous coronary intervention. It describes four techniques for advancing a wire in an occlusion: sliding, drilling, penetrating, and push and torque. It then outlines various antegrade and retrograde approaches, including antegrade loose tissue tracking, antegrade intimal plaque tracking, antegrade sub-intimal tracking, antegrade kissing technique, retrograde true lumen puncture, controlled antegrade and retrograde sub-intimal tracking (CART), reverse CART, and the knuckle wire technique. Complications that can occur during CTO PCI are also listed.

1. WALKING THROUGH ATHROUGH A CHRONICTOTAL
OCCLUSION
Dr Ramachandra

3. A wire can be advanced in the occlusion
1. Sliding technique
2. DrillingTechnique
3. PenetratingTechnique
4. Push andTorqueTechnique

4. CTO approaches
■ Antegrade
■ Retrograde

5. Anterograde
■ Antegrade loose tissue tracking
■ Antegrade intimal plaque tracking
■ Antegrade sub-intimal tracking

6. Retrograde
1. Antegrade KissingTechnique
2. RetrogradeTrue Lumen Puncture
3. Controlled Antegrade and Retrograde Sub-IntimalTracking (CART)
4. Reverse CART
5. Knuckle wire technique (KWT)

7. Antegrade KissingTechnique
1. This is the shortest possible technique
2. Both the antegrade and retrograde wire are in true lumen and the CTO segment
3. Crossed antregradely using the tip of retrograde wire as a marker

8. RetrogradeTrue Lumen Puncture
■ Crossed retrograde BUT the tip of antegrade wire as a marker

9. Controlled Antegrade and Retrograde
Sub-IntimalTracking (CART)
■ Antegrade wire is intimal but retrograde wire is sub-intimal
■ Least favourable of all techniques
■ Dilatation of retrograde sub-intimal space with a balloon
■ Antegrade wire is then used to pierce this retrograde sub-intimal space guided by
inflated retrograde balloon to enter into true distal lumen

10. Reverse CART
■ The most utilized technique
■ Retrograde wire is then used to pierce the occluded segment in sub-intimal space
guided by inflated anterograde balloon to enter into true proximal lumen

11. Complications during CTO PCI
1. Thrombosis and dissection of donor artery
2. Perforation of the Collateral Channel
3. Collateral Ventricular fistula
4. Septal Hematoma
5. Entrapment of PCI equipment in septal
collaterals
6. Sub-intimal stenting
7. Radiation skin injury
8. Contrast Induced Nephropathy

12. Other than me is a teacher