Debate: Is there a difference between RDR and reverse CART? – Yes
Hsien-Li Kao, Taipei, Taiwan
11th Experts Live CTO
The annual Euro CTO meeting
September 13th –14th, 2019 - Berlin, Germany
Debate: Is there a difference between RDR and reverse CART? – Yes
1. P A U L H S I E N - L I K A O , M D
P R O F E S S O R O F M E D I C I N E
N A T I O N A L T A I W A N U N I V E R S I T Y H O S P I T A L
Reverse CART is not RDR
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2. Disclosure
I have nothing to disclose relevant to the following presentation
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3. Goal of CTO PCI – no argument
Re-open the occluded segment, maintaining patency of pertinent side
branches and outflow vessels, and re-perfuse the ischemic bed, with
safety and efficiency
Success should provide anginal relief, improve exercise tolerance and
LV function, reduce need for CABG, and even long-term survival
Not just TIMI3 flow with <20% residual diameter stenosis!!
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6. Are they the same ideas?
Very frequently used interchangeably in the “HTBRID universe”
Riley RF, et al. Cathet Cardiovasc Interv 2019
Brilakis ES, et al. JACC Intv 2012
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7. But RWE and RDR are mutually exclusive
Brilakis ES, et al. J Am Coll Cardiol Intv 2012 Sianos G, et al. EuroIntervention 2018
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8. RDR the violent way: intentional knuckling
DeMartini TJ, et al. Intervent Cardiol Clin 2012
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9. And r-CART is based on RWE
Aim to preserve
distal cap, and space
creation within
plaque
Theoretically less
side branch loss,
especially in-
segment and distal
ones
Joyal D, et al. J Am Coll Cardiol Intv 2012
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10. APCTO and EuroCTO only knuckle conditionally
Wu EB, et al. AsiaIntervention 2018 Galassi A, et al. Eurointervention 2019
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11. We want r-CART even less traumatic when plausable
Matsuno S, et al. Eurointervention 2018
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12. r-CART
Should be wire-based and started with RWE, different from RDR
Minimal space (intentionally only within the plaque) creation for wire
connection
“The most commonly used method to connect the proximal and distal
true lumen … if retrograde true lumen crossing attempts are
unsuccessful.”
We should try to stay within the plaque from cap to cap, and knuckle
should only be done within the occluded segment when necessary
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Brilakis ES, et al. JACC Intv 2012
13. My argument 2
r-CART (especially wire-based) is better than RDR
Because by staying within the plaque and in between the caps, we can
have better outcome
And that’s why we should differentiate r-CART from RDR
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14. SI tracking related to bad outcome
Florence CTO Registry data
Valenti R, et al. J Am Coll Cardiol 2013
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16. Up to 40% retrograde will result in SI tracking
Tsujita K, et al. J Am Coll Cardiol Intv 2012
NYPH/CUMC data J-PROCTOR data
Muramatsu T, et al. EuroIntervention 2014
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17. RDR: more SI tracking and longer stents
Song L, et al. J Am Coll Cardiol Intv 2017
NYPH/CUMC data
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18. And SI tracking means trouble
Song L, et al. J Am Coll Cardiol Intv 2017
NYPH/CUMC data
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19. SI in retrograde means more stent and TVR
Hasekawa K, et al. EuroIntervention 2017
J-PROCTOR 2 data
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25/81
=31%
20. Conclusions
RDR and r-CART are different
Staying intraplaque gives you the best procedural and long term
outcomes
Don’t win the battle (TIMI 3, <20% RS) while losing the whole war
(TVR, ischemic relief)!
Remember the non-CTO community is asking seriously for evidence for
clinical benefits over OMT!
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21. But r-CART not necessarily means knuckle
Brilakis ES, et al. Catheter Cardiovasc Interv 2012
22. But r-CART not necessarily means knuckle
Brilakis ES, et al. Catheter Cardiovasc Interv 2012