Complex Right Coronary Artery CTO Procedure: Step-by-Step antegrade dissection reentry technique

This complete didactic procedure concerns a 72 yo male, with history of lateral STEMI (OM Stenting). The coronary angiography has also shown proximal RCA Chronic total occlusion with residual proven ischemia.

This RCA Chronic total occlusion was recanalized antegradly using antegrade-dissection-reentry (ADR) technique explained step-by-step by a Proctor expert in ADR.

Educational objectives

• How to manage patients with Coronary Chronic total occlusions.
• How to  plan intervention strategy using the Hybrid algorithm.
• How to perform Knuckle wire technique.
• Optimal application of the  antergrade controlled dissecion using the CossBoss microcatheter.
• Optimal preparation of the Stingray balloon.
• How to perform reentry technique with Stingray guidewire.
• Proctoring importance in optimal learning  curve of ADR technique.

Step-by-Step procedure

• Dual Radial access : Left Radial 7F for the right & Right radial 6F for the left system.
• AL0.75 7F in the RCA & EBU 4.0 6F in the LM.
• Dual lumen injections and angiographic studying of the lesion (Proximal CAP, Length, Distal vessel, Collaterals).
• Approach :antegrade wire escalation, if failed : Antegrade-Dissection-reentry as first strategy.
• Pilot 200 Guidewire with a MAMBA  microcatheter (Boston Scientific) failed to engage the Proximal CAP.
• Engaging the Proximal CAP with Confianza Pro 12 guidewire.and switch again to Pilot200.
• Advancing the Pilot 200 as Knuckle wire Technique.
• Retreiving the MAMBA microcatheter using the Trapper Catheter (Boston Scientific) to limit the risk of significant hematoma.
• Advancing the CrosBoss catheter in the subintimal space with Pilot 200 guidewire inside.
• Stingray preparation while CrossBoss is in the Subintimal space.
• Retreiving the CrosBoss Catheter using the Trapper and advancing the Stingray balloon.
• Getting the optimal Stingray Projection for reentry.
• Reentry technque using the Stingray guidewire.
• Retreiving the Stingray balloon using Trapper & Advancing the MAMBA microcatheter over the Stingray guidewire.
• Advancing a regular guidewire to the distal RCA.
• Predilatation with a 4.0x20mm.
• Stenting with two 4.0x38mm Synergy stents. and additional 4.0x24mm Synergy stent.

Biobliography

• Optimal approach to percutaneous intervention for CTO in 2017: a hybrid strategy is now the preferred choice - Editorial
  Authors:Simon J. Walsh, MD, FRCP; Colm G. Hanratty, MD, FRCP; James C. Spratt, MD, FRCP
   
• Antegrade Dissection and Reentry as Part of the Hybrid Chronic Total Occlusion Revascularization Strategy: A Subanalysis of the RECHARGE Registry (Registry of CrossBoss and Hybrid Procedures in France, the Netherlands, Belgium and United Kingdom). - Article
  Authors:Maeremans J, Dens J, Spratt JC, Bagnall AJ, Stuijfzand W, Nap A, Agostoni P, Wilson W, Hanratty CG, Wilson S, Faurie B, Avran A, Bressollette E, Egred M, Knaapen P1, Walsh S; RECHARGE Investigators
  Publication :Circ Cardiovasc Interv. 2017 Jun;10(6). pii: e004791. doi: 10.1161/CIRCINTERVENTIONS.116.004791.
   
• Randomized Comparison of a CrossBoss First Versus Standard Wire Escalation Strategy for Crossing Coronary Chronic Total Occlusions: The CrossBoss First Trial. - Article
  Authors: Karacsonyi J, Tajti P, Rangan BV, Halligan SC, Allen RH, Nicholson WJ, Harvey JE, Spaedy AJ, Jaffer FA, Grantham JA8, Salisbury A, Hart AJ8, Safley DM, Lombardi WL, Hira R, Don C, McCabe JM, Burke MN, Alaswad K,  Banerjee S, Brilakis ES
  Publication: Interv. 2018 Feb 12;11(3):225-233. doi: 10.1016/j.jcin.2017.10.023.
   
• Procedural and longer-term outcomes of wire- versus device-based antegrade dissection and re-entry techniques for the percutaneous revascularization of coronary chronic total occlusions.- Article
  Authors:Azzalini L, Dautov R, Brilakis ES, Ojeda S, Benincasa S, Bellini B, Karatasakis A, Chavarría J, Rangan BV, Pan M, Carlino M, Colombo A, Rinfret S.
  Publication:Int J Cardiol. 2017 Mar 15;231:78-83. doi: 10.1016/j.ijcard.2016.11.273. Epub 2016 Nov 16.
   
• Use of antegrade dissection re-entry in coronary chronic total occlusion percutaneous coronary intervention in a contemporary multicenter registry. - Article
  Authors: Danek BA, , Alaswad K,  Yeh RW4, Jaffer ing A, MoseN, Garcia S, Rangan BV, Thompson CA, Banerjee S, Brilakis ES.
  Publication:Int J Cardiol. 2016 Jul 1;214:428-37. doi: 10.1016/j.ijcard.2016.03.215. Epub 2016 Apr 6.