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Live case #5 from Swiss CTO Summit 2019 - Dr Avran & Dr Faurie
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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?
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
RCA distal branch sizing
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