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This didactic procedure  concerns a patient with history  of CAD : CABG ( Saphenous vein to the Diagonal-LAD), presenting severe symptomatic severe stenosis of the distal Graft anastomosis and Ostial LAD CTO, he has underwent  successfull retrograde recanalization through the Saphenous vein & Stenting with good final result.

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Educational objectives

• Different options to approach patients with native vessels CTO & CABG.
• Retrograd native vessel CTO  recanalization through saphenous vein Graft.
• How to approch bifurcations in CTO lesions.
• How to perform TrapLiner assisted Reverse-CART technique.
• Dual Lumen microcatheters in CTO procedures.
• IVUS for guidance & optimization during complex CTO procedures.

Step-by-Step Procedure

• Double Femoral 8F Access with 45cm long sheaths.
• EBU 3.75 8F into the LM & AL1 8F into the Saphenous vein graft.
• Workhorse wire Sion blue (Asahi) into the distal Left Circumflex.
• First Antegrade approach using Gaia 2 guidewire (Asahi) & Corsair Pro microcatheter (Asahi).
• Workhorse guidewire Sion Blue into the Saphenous vein Graft distal to the LAD.
• Advancing a second microcatheter Caravel (Asahi) into the distal Vein Graft near the distal CAP.
• Trapping the Antegrade microcather using a TrapLiner (Teleflex).
• Predilatation of the proximal CTO segment with a 2.0 Sequent (Braun) Balloon to facilitate the TrapLiner Reverse-CART technique.
• Performing Antegrade Knuckle wire with Miracle (Asahi) to be sure being in the vessel.
• Performing TrapLiner assisted Reverse-CART technique using 3.0x20mm Sequent (Braun) Balloon and Gaia 3 guidewire (Asahi).
• Externalization of the RG3 guidewire(Asahi).
• Advancing a dual lumen microcatheter Fine Duo (Terumo) antegradely toward the diagonal.
• Crossing the lesion antegradely toward the LAD using the dual Lumen microcatheter & a Workhorse Guidewire Sion Blue (Asahi).
• Predilatation of the CTO.
• IVUS evaluation.
• Long Stenting from the Left Main to the Mid LAD with overlapping Stents: Coroflex ISAR Neo (Braun).
• IVUS evaluation & Optimization.
• Final result.
• Access Closure using Angioseal 8F Closure device.

Biobliography

• A percutaneous treatment algorithm for crossing coronary chronic total occlusions.ink title - Article
  Authors:Brilakis ES, Grantham JA, Rinfret S, Wyman RM, Burke MN, Karmpaliotis D, Lembo N, Pershad A, Kandzari DE, Buller CE, DeMartini T, Lombardi WL, Thompson CA.
  Publication: 2012 Apr;5(4):367-79. doi: 10.1016/j.jcin.2012.02.006.

• Recanalization of Chronic Total Occlusions in Patients With Previous Coronary Bypass Surgery and Consideration of Retrograde Access via Saphenous Vein Grafts.- Article
  Authors:Dautov R, Manh Nguyen C, Altisent O, Gibrat C, Rinfret S.
  Publication: 2016 Jul;9(7). pii: e003515. doi: 10.1161/CIRCINTERVENTIONS.115.003515.

• Use of Saphenous Vein Bypass Grafts for Retrograde Recanalization of Coronary Chronic Total Occlusions: Insights From a Multicenter Registry..- Article
  Authors:Nguyen-Trong PK, Alaswad K, Karmpaliotis D, Lombardi W, Grantham JA, Lembo N, Kandzari D, Karatasakis A, Karacsonyi J, Danek BA, Rangan BV, Roesle M, Ayers CR, Thompson CA, Banerjee S, Brilakis ES.
  Publication: J Invasive Cardiol. 2016 Jun;28(6):218-24.

• Intravascular Ultrasound Guided Percutaneous Coronary Intervention for Chronic Total Occlusionink title - Abstact
  Authors:Dash D, Li L.
  Publication:2015 Nov 6;11(4):323-317. doi: 10.2174/1573403X11666150909105827.
   
• Chronic Total Occlusion Interventions: Update on Current Tips and Tricks.ink title - Article
  Authors:Tajti P, Xenogiannis I, Karmpaliotis D, Alaswad K, Jaffer FA, Nicholas Burke M, Ungi I, Brilakis ES.
  Publication: 2018 Oct 22;20(12):141. doi: 10.1007/s11886-018-1083-7.