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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
Bibliography
Shooting date : 2019-11-08
Last update : 2021-05-11
Last update : 2021-05-11
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Al fazir O. beautiful case
Arun K. Nicely executed!
Yasser H. Great job team
Benjamin F. Thank you for your feed-back!
ahmed B. Nice duoet
Eli P. Very interesting!