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Case of the month: February 2020 - Live case from Swiss CTO Summit 2019

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 


  • 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


  • 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


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