This document discusses techniques for crossing chronic total occlusions (CTOs) during percutaneous coronary intervention. It describes the distal cap penetration technique using a reverse controlled antegrade and retrograde subintimal tracking (CART) approach. Key aspects of CTO wiring are discussed, including wire features needed for penetration, pushability, steerability, and shaping memory. Retrograde strategies and hardware options are presented, including parallel wiring, the star technique, and snaring. The document shares experience from over 300 CTO cases with a high success rate and low complications.

1. DISTAL CAP PENETRATION –
Cart Vs REVERSE CART
Dr .V. Surya Prakasa Rao
HOD – Cardiology Department
Apollo Hospitals –Hyderguda, Hyderabad.

6. Antegrade Retrograde
Approach

7. CLASSIFICATION – Retrograde
Procedures

8. CART Technique

11. Position of Retrograde wire.

12. A B C
D E

13. Retro Grade Strategy

15. A B C
D
E

17. CTO

18. Corsair Difficult to Negotiate at an
Acute Bend

19. Corsair induced Subintimal
Haematoma

20. CTO Wire
Features required for CTO wires
1. Penetration force for penetrating proximal
fibrous cap and advancing into true lumen
2. Pushability for crossing chronic occlusions and
complex lesions with heavy calcifications and
tough fibrous tissues.
3. Steerability for easy manipulate in various
directions with good torque transmission
4. Shaping Memory of the tip

21. CTO Wire

22. CTO Wire

23. CTO Wire

25. CTO Wiring

26. CTO Wiring – Tip Shaping

27. CTO – Wire Manipulation

29. 1st CTO LIVE SUMMIT
June 8th and 9th 2013
at
MUMBAI

31. COMPLEX CTO – CHOOSING THE
RIGHT HARDWARE.
Dr .V. Surya Prakasa Rao
HOD – Cardiology Department
Apollo Hospitals –Hyderguda, Hyder

32. CTO Wiring

33. CTO

34. CTO

35. CTO

36. CTO

37. Low Profile Balloons
• ACROSTAT – 1.1mm.
• FALCON – 1.0mm.
• SAPHIRE- 1.0mm.
• MINI TREK – 1.25mm (Hydrophilic).
• TERUMO - 1.25mm.

38. Antegrade Parallel Wire Technique

39. Strategy :
• 7F Femoral approach and
5F Trans Radial for Contralateral Injection.
• XB / EBU / Amplatz.
• Plastic Jacket: Fielder XT.
• Conquest / Confluenza / Miracle – Parallel wire.
• Micro catheter – Corsair.
• Low Profile Balloons.
• DES

40. CTO

41. CTO Wire

42. CTO Wire

43. CTO Wire

44. SB Parallel wire with GAIA crossing

45. CRUSADE

46. GAIA Wire

47. Antegrade IVUS guided.

48. CTO Wiring

49. Star Technique

50. Cont..

51. Cross Boss catheter

52. String Ray

53. TORNUS

54. TORNUS

55. ISR - CTO
Fielder XT with
Contralateral
Injection

56. ISR - CTO

57. Retro Grade Strategy

58. Ostial LAD CTO – Reverse CART
• 7F / 8F – short guiding ( customized / self made) with
SH.
• 135 / 154 cm Corsair.
• SION Blue - 0.014 ( Fielder XT, Conquest Pro12,
Miracle3 / 9, Fielder XTR)
• RG3 – 300cms.
• Volcano IVUS – Eagle Eye Gold.
• 2.5 / 3.0 mm NC Balloons.
• Snare.
• Coils.
• Covered Stent

62. Snare: Gooseneck

63. Covered Stent

64. COILS WITH DELIVERY CATHETER

65. Pericardiocentesis Tray

67. CTO – CACTO Experience
• Total No of CTO’S-2006 to Dec 2012 : 326
cases
• Success rate 89.9 %
• Major complications: < 1%

68. 1st CTO LIVE SUMMIT
June 8th and 9th 2013
at
MUMBAI

70. GUIDEWIRES - CTO