14th Experts Live CTO September 2nd - 3rd, 2022 - Mainz, Germany Main Session - Session 5: Retrograde – Technical aspects Reverse CART – State of the art Georgios Sianos, Thessaloniki, Greece Room: Guteberg Hall (Auditorium) - Saturday 10:20 Chairmen: Alfredo Galassi, Palermo, Italy; Dimitrios Karmpaliotis, Morristown, USA; Nicolaus Reifart, Königstein, Germany

1. Prof. GEORGIOS SIANOS, MD, PhD, FESC
AHEPA UNIVERSITY HOSPITAL
THESSALONIKI, GREECE
Aristotle University
of Thessaloniki
A’ Cardiology Department
AHEPA University Hospital
REVERSE CART – STATE OF THE ART

2. I HAVE NO CONFLICT OF INTEREST
RELATED TO THIS PRESENTATION

3. (J Invasive Cardiol 2006;18:334-8)
Concept of CART technique
Controlled Antegrade and Retrograde subintimal Tracking

4. CART technique

5. MICROCATHETER CLASSIFICATION
Vammou et al. Expert Rev Med Devices. 2019 Apr;16(4):267-273

6. ▪ CLASSIC UNCOMPLICATED X-CART
▪ GUIDING CATHTER EXTENTION X-CART
▪ IVUS GUIDED XCART
▪ COMPLICATED X-CAT (DIFFICULT TO MAKE CONNECTIONS)
▪ X-CART IN BIFURCATED CTOs
▪ X-CART THROUGH STENTS
PREAMBLE TO THIS PRESENTATION

7. DIAGNOSTIC ANGIOGRAM
COLLATERAL TIP INJECTION
AFTER LAD TREATMENT

8. COLLATERAL CROSSING
SION WIRE
PERIPHERAL TIP INJECTION

9. FAILED RETROGRADE WIRE CROSSING

10. REVERSE CART TECHNIQUE

11. RETROGRADE WIRE CROSSING AND MICROCATHETER ADVANCMENT
IN PROXIMAL TRUE LUMEN AND MICROCATHETER

12. FINAL RESULT

13. DIAGNOSTIC CORONARY ANGIOGRAPHY
Bilateral contrast injection

14. ANTEGRADE WIRING
Switch to retrograde after 10 min of radiation time

15. RETROGRADE APPROACH
CORSAIR SION SELECTIVE CONTRAST INJECTION

16. RETROGRADE APPROACH
SELECTIVE CONTRAST INJECTION

17. RETROGRADE APPROACH
CORSAIR EXCHANGED TO FINECROSS

18. SELECTIVE CONTRAST INJECTION
RETROGRADE APPROACH

19. GCE ASSISTED X-CART
GAIA SECOND

20. GUIDELINER ENGAGMENT
Trapping technique, retrograde MC
advancement

21. FINAL RESULT

22. BILATERAL CONTRAST INJECTION

23. ANTEGRADE ATTEMPT

24. SWITCH TO RETROGRADE APPROACH

25. SELECTIVE INJECTION TO DELINEATE CRUX ANATOMY

26. SELECTIVE INJECTION TO DELINEATE CRUX ANATOMY

27. PLA
PDA
SVG GRAFT
SCHEMATIC CRUX ANATOMY

28. RETROGRADE WIRING AT THE CRUX

29. SECOND RETROGRADE CROSSING

30. REVERSE CART TECHNIQUE

31. DILATATIONS AT THE CRUX OVER RG3 WIRE

32. GUIDION AT CRUX TO FACILITATE RETROGRADE WIRING FROM PDA

33. GUIDION AT CRUX TO FACILITATE RETROGRADE WIRING FROM PDA

34. TRAPPING TECHNIQUE INSIDE GUIDION; RETROGRADE WIRE AND MC CROSSING

35. FINAL RESULT

36. IVUS GUIDANCE IN XCART

37. 55Y MALE, MID RCA CTO, BLUNT STUMP WITH RETROGRADE
COLLATERALS . FAILURE ANTEGRADE ATTEMPT
SECOND ATTEMPT
courtesy R. Garbo

38. IVUS GUIDED PUNCTURE FOR ENTRY POINT WITH HORNET 14
AND FAILURE : SUBINTIMAL IN DISTAL RCA

39. RETROGRADE APPROACH: REVERSE CART WITH 2.5MM BALLOON DISTAL
AND FAILURE IN DISTAL RE-ENTRY WITH GUIDEZILLA 6F

40. DISTAL RCA NO CONNECTION:
IVUS SUBINTIMAL, RETROGRADE WIRE INTIMAL
TYPE 4 SITUATION

41. MID RCA GOOD CONNECTION:
BOTH WIRE IN THE INTIMAL SPACE
Type 1 situation

43. FIRST INJECTION AFTER RE-ENTRY AND STENTING

56. DIAGNOSTIC CORONARY ANGIOGRAPHY

57. RETRORADE WIRE AND MC ADVANCED

58. GUIDION FACILITATED REVERSE CART TECHNIQUE

59. RETRORADE WIRE AND MC INSIDE GC

60. RCA FINAL RESULT

61. LCX RECANALIZATION; SEPTAL COLLATERAL CROSSING

62. RETROGRADE WIRING UNSUCCESSFUL
Wire behind the stent struts

63. ENHANCER RX ANTEGRADE

64. REVERSE CART TECHNIQUE

65. PING PONG TECHNIQUE

66. LCX FINAL RESULT

76. RETROGRADE WIRE SWING

77. LM HAEMATOMA

88. RETROGRADE STENT WIRE CROSSING

94. Matsuno et. Al. EuroIntervention 2018;14:94-101
OVERVIEW AND PROPOSED TERMINOLOGY FOR THE REVERSE CONTROLLED
ANTEGRADE AND RETROGRADE TRACKING (REVERSE CART) TECHNIQUES

95. CTO CROSSING WIRE-BASED TERMINOLOGY

96. ▪ GOOD ALLIANCE OF THE ANTEGRADE AND RETROGRADE WIRE (DANCING TOGETHER)
▪ BRING AS CLOSE AS POSSIBLE ANTEGRADE/RETROGRADE GEARS
▪ CHECK IN AT LEAST TWO PERPENDICULAR PROJECTIONS
▪ ALWAYS GCE IN OSTIAL LAD OCCLUSIONS (CAVE SUBINTIMAL LM WIRE COURSE)
▪ IMAGING WHEN ANTEGRADE AND RETROGRADE WIRES ARE DISTANT OR
UNEXPECTEDLY DIFFICULT TO MAKE THE CONNECTION
▪ LIMIT THE SIZE OF THE BALLOON TO MINIMIZE VESSEL SUBINTIMAL INJURY
▪ TRY TO AVOID CREATION OF LARGE SUBINTIMAL SPACES (LIMIT KNUCKLE SIZE)
▪ BIDIRECTION KNUCKLE IN VERY TORTOUS CTOs TO CLARIFY VESSEL COURSE AND SOLVE
VESSEL AMBIGUITY
▪ AIM IN CONNECTION WITHIN THE OCCLUDED SEGMENT AVOIDING PROXIMAL AND
DISTAL PRESERVED LUMEN
▪ TRY TO RESPECT OSTIUM OF BIG SIDE BRANCHES TO MINIMIZE THEIN ATTRITION
▪ X-CART IS THE TECHNIQUE OF CHOICE WHEN CROSSING STENTS RETROGRADE WHEN
RECANALIZING SIDE VESSELS IN BUFURCATION CTOs WITH OR WITHOUT GCE
▪ IN LONG IN-STENT OCCLUSION MINIMIZE OUT OF STENT CROSSING
▪ BE READY TO IMPROVISE AS COMPLEXITY INCREASES……….
TAKE HOME MESSAGES

97. ▪ GOOD ALLIANCE OF THE ANTEGRADE AND RETROGRADE WIRE (DANCING TOGETHER)
▪ BRING AS CLOSE AS POSSIBLE ANTEGRADE/RETROGRADE GEARS
▪ CHECK IN AT LEAST TWO PERPENDICULAR PROJECTIONS
▪ ALWAYS GCE IN OSTIAL LAD OCCLUSIONS (CAVE SUBINTIMAL LM WIRE COURSE)
▪ IMAGING WHEN ANTEGRADE AND RETROGRADE WIRES ARE DISTANT OR
UNEXPECTEDLY DIFFICULT TO MAKE THE CONNECTION
▪ LIMIT THE SIZE OF THE BALLOON TO MINIMIZE VESSEL SUBINTIMAL INJURY
▪ TRY TO AVOID CREATION OF LARGE SUBINTIMAL SPACES (LIMIT KNUCKLE SIZE)
▪ BIDIRECTION KNUCKLE IN VERY TORTOUS CTOs TO CLARIFY VESSEL COURSE AND SOLVE
VESSEL AMBIGUITY
▪ AIM IN CONNECTION WITHIN THE OCCLUDED SEGMENT AVOIDING PROXIMAL AND
DISTAL PRESERVED LUMEN
▪ TRY TO RESPECT OSTIUM OF BIG SIDE BRANCHES TO MINIMIZE THEIN ATTRITION
▪ X-CART IS THE TECHNIQUE OF CHOICE WHEN CROSSING STENTS RETROGRADE WHEN
RECANALIZING SIDE VESSELS IN BUFURCATION CTOs WITH OR WITHOUT GCE
▪ IN LONG IN-STENT OCCLUSION MINIMIZE OUT OF STENT CROSSING
▪ BE READY TO IMPROVISE AS COMPLEXITY INCREASES……….
TAKE HOME MESSAGES