Live case #5 from Swiss CTO Summit 2019 - Dr Avran & Dr Faurie

Educational objectives

• What to do when usual antegrade and retrograde approach failed? Consider the use of « knuckle » technique with « REVERSE CART » technique (by experienced operators)
• Do we have to carry out a CTO when the distal branch appears poorly developed?
• Which guiding catheter to choose when you have pressure damping? Consider the use of side holes guiding catheter
• How to choose the right microcatheter
• « Knuckle » technique: which guidewire?  Consider the use of a soft polymer wire
• How to facilitate « REVERSE CART » technique? Consider the use of a catheter extension
• Perform an IVUS: is this determining? 

Step-by-step procedure

• New try of RCA CTO recanalisation with REVERSE CART technique by circumflex epicardial channel after standard antegrade and standard retrograde failure (no other possibilty: septal from LIMA are not connected with PDA)
• Antegrade approach with AL 1, 7F (side holes guiding catheter due to ostial lesion),
• Retrograde approach with EBU 4, 7F

1) Retrograde approach (epicardial channel from circumflex)

• Microcathter: MAMBA FLEX
• First wire: SION BLUE, second wire : SION
• MAMBA FLEX microcatheter and SION wire are in front of the distal cap after antegrade injection

2) Antegrade approach (RCA)

• Microcathter: MAMBA FLEX
• First wire: GAIA 3rd to perform the proximal cap puncture
• Second wire: FIELDER XTA with small bend to perform « knuckle technique »
• Stop just before the distal cap

3) « Knuckle », retrograde approach

• « Knuckle technique » with GAIA 3rd 

4) REVERSE CART

• Remove the anterograde MAMBA FLEX
• Catheter extension GUIDEZILLA 7F
• Use 2.5 balloon to carry out the REVERSE CART
• Retrograde fresh Gaia 3rd wire to perform REVERSE CART
• Externalise the wire
• Pull back the retrograde MAMBA FLEX to perform an IVUS

5) IVUS

• RCA distal branch sizing 

6) Angioplasty

• Predilatation with 2mm balloon
• 2.5*24 mm DES in the PDA
• Two DES in the RCA (3*48mm, 3*38mm) up to the ostium
• 1.5 balloon in the crux to PL branch