Very complex Mid RCA occlusion

This 40 minutes didactic recorded procedure concerns a symptomatic coronary artery disease patient with a very old long complex mid-RCA occlusion (J-CTO score 4) first attempted retrogradely and then antegradely, using modern strategy and latter tools for coronary artery recanalization.

Step-by-Step Procedure:

• Description of RCA occlusion and collaterals
• Main steps of retrograde approach through a diseased LAD. Septal surfing
• Guidewire escalation for retrograde re-entry
• Antegrade connection and reverse CART technique
• Placement of Guiding extension and Rendez-vous technique
• Externalization of guidewire
• Predilatation with long balloon
• Occlusion and distal RCA & mid LAD Stenting
• Main steps summary of this complex procedure 
   

Learning points:

• Management of double arterial access: radial & femoral
• Antegrade approach
• Retrograde approach
• Septal Artery surfing
• Guidewire escalation
• Trapping balloon technique
• Reverse CART technique
• Rendez-vous technique
• Guidewire externalization 
   

Bibliography:

• Fully Transradial versus Transfemoral approach for percutaneous intervention of coronary Chronic Total Occlusions applying the hybrid algorithm: insights from RECHARGE Registry - Article
   
• Management of Chronic Total Coronary Occlusion in stable ischemic heart disease by Percutaneous Coronary Intervention versus Coronary Artery Bypass Grafting versus medical therapy - Article
   
• Contemporary incidence, Management, and long-term outcomes of Percutaneous Coronary Interventions for Chronic Coronary Artery Total Occlusions:Insights from the VA CART program - Article
  JACC Cardiovasc Interv. 2017 May 8;10(9):866-875