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Educational objectives

• How to manage patients with coronary CTO.
• How to apply the Hybrid algorithm during coronary CTO procedures.
• How to perform antegrade Knuckle wire Technique.
• How to select & approach epicardial collaterals.
• How to perform Reverse CART Technique.

Step-by-Step Procedure

• Double Access: Right Femoral 7F, Left Radial 6F.
• Dual injection & angiographic evaluation.
• Antegrade approach using Turnpike Spiral (Teleflex) & Fielder XT-A (Asahi) and then Gaia 3rd guidewire (Asahi).
• Antegrade wire Knuckling to the distal RCA using Fielder XT-A.
• Distal re-entry failure with Pilot 200 (Abbott).
• Retrograde Approach using epicardial collaterals from Left Cx: Sion guidewire (Asahi) & Turnpike LP (Teleflex).
• Revere CART technique using a 3.5x20mm balloon, guideliner V3 support (Teleflex) & Pilot 200 guidewire (Abbott).
• Predilatation.
• Stenting with multiple  DES  Supraflex (Teleflex).
• Left system microcatheter removing & control.
• Final result.

Protocol

• Procedural time: 120min.
• Contrast medium: 310ml (Ultravist)
• Exposure: 1.6 Gy.
• Fluoroscopic time: 65min.

Biobliography

• Optimal approach to percutaneous intervention for CTO in 2017: a hybrid strategy is now the preferred choice - Editorial
  Authors: Simon J. Walsh, MD, FRCP; Colm G. Hanratty, MD, FRCP; James C. Spratt, MD, FRCP
  
   
•  Epicardial collateral channel for retrograded recanalization of chronic total occlusion percutaneous coronary intervention: Predictors of failure and procedural outcome.- Article
  Authors: Huang Z, Ma D, Zhang B, Folson AA, Lin J, Wu K, Liao H, Zhong Z.
  Publication: 2018 Feb;31(1):23-30. doi: 10.1111/joic.12441. Epub 2017 Sep 19
   
• Outcomes of the retrograde approach through epicardial versus non-epicardial collaterals in chronic total occlusion percutaneous coronary intervention. - Article
  Authors: Benincasa S, Azzalini L, Carlino M, Bellini B, Giannini F, Zhao X, Colombo A.
  Publication: 2017 Sep;18(6):393-398. doi: 10.1016/j.carrev.2017.03.013. Epub 2017 Mar 14.
   
• Retrograde approach for the recanalization of coronary chronic total occlusion: collateral selection and collateral related complication. - Article
  Authors: Ma JY, Qian JY, Ge L, Fan B, Wang QB, Yan Y, Zhang F, Yao K, Huang D, Ge JB.
  Publication:2013 Mar;126(6):1086-91.
   
• Intracoronary snaring of the retrograde guidewire: How to overcome extreme takeoff angles in chronic total occlusion percutaneous coronary intervention. - Article
  Authors: Azzalini L, Candilio L, Carlino M, Colombo A.
  Publication:2018 Feb 15;91(3):464-469. doi: 10.1002/ccd.27324. Epub 2017 Sep 25.