14th Experts Live CTO September 2nd - 3rd, 2022 - Mainz, Germany Main Session - Session 5: Retrograde – Technical aspects Externalisation Failure – What next? Nicolas Boudou, Bordeaux, France Room: Guteberg Hall (Auditorium) - Saturday 10:45 Chairmen: Alfredo Galassi, Palermo, Italy; Dimitrios Karmpaliotis, Morristown, USA; Nicolaus Reifart, Königstein, Germany

1. Esternalisation failure – What next?
Nicolas Boudou, MD
Clinique Saint - Augustin
Bordeaux

2. Potential conflicts of interest
Speaker's name: Dr Nicolas Boudou
 CTO proctoring: Terumo, Asahi Intecc, Boston SC
 FORM A: score 2
 FORM B: score 2

3. 1. CTO crossed by the microcatheter, advanced into antegrade GC
2. Guidewire across the lesion, inside the antegrade guiding catheter for lesion preparation and stenting:
➢ Externalisation of a long guidewire (> 300cm). If needed : Snare, guide catheter extension
➢ Tip in: Antegrade guidewire in the retrograde microcatheter OR retrograde guidewire in an antegrade microcatheter
After retrograde CTO wire crossing

4. The microcatheter should cross the CTO, before exchange
with a long guidewire for externalisation
Trapping balloon in the antegrade GC
• The retrograde wire trapped by a balloon in the antegrade GC.
• Especially for retrograde through epicardial collateral.
How to help retrograde crossing by microcatheter

5. Trapping balloon to cross the CTO with the microcatheter

6. Trapping balloon
Trapping balloon in the antegrade GC to help the retrograde microcatheter to cross and reach the
antegrade GC.
Trapping balloon to cross the CTO with the microcatheter

7. • Long guidewires ≥ 300cm are mandatory (not a workhorse wire with an
extension!), RG3, R350,….
• Through the retrograde microcatheter into the antegrade guiding
catheter (GC)
• Retrograde wire exit through introducer in the antegrade valve
Externalisation

8. Externalisation: causes of failures
- Failure to wire the antegrade GC:
Aorto-ostial CTOs, large vessel, non coaxial GC position
➔ After crossing an aorto-ostial CTO with the microcatheter and long guidewire ➔ SNARE
- Microcatheter too short to reach the antegrade guiding catheter?
- Retrograde microcatheter can’t cross de CTO despite anchoring?

9. Guide catheter extension (GCE) for externalisation
➔ GCE for a better alignment, coaxility
➔ GCE to lengthen the antegrade guiding catheter
• Long collateral (epicardial, bypass) +++
• Retrograde guiding catheter too long
➔ GCE to facilitate the Reverse CART
M. Vo and E. Brilakis, CCI 2014

10. CTO post CABG: retrograde through bypass

11. Retrograde through saphenous graft/ marginal ➔ GCE assisted Reverse CART

12. Antegrade GCE to lenghten Guiding catheter and trapping balloon ➔ externalisation
Trapping balloon
GCE

14. Externalisation failure – What next?

15. Retrograde microcatheter can’t cross the CTO
Microcatheter inside the plaque with calcifications, tortuosities….
➔Lesion preparation (before CTO crossing):
➔Antegrade (BASE, Knuckle, …) ++++ and try another retrograde crosssing in a less calcified or fibrotic zone
(dissection and reentry by Reverse CART)
➔Retrograde: Retrograde Carlino? CART?
➔ Tip in (after CTO crossing):
• Retrograde guidewire inside an antegrade microcatheter
• Antegrade microcatheter dedicated to cross resistant, fibrotic proximal cap: Turnpike Spiral, Mamba,…

16. Tip In: retrograde wiring an antegrade microcatheter
RCA: long CTO, Ca++, tortuosities

17. Tip In: retrograde wiring an antegrade microcatheter

18. Tip In: retrograde wiring an antegrade microcatheter
• Failure to cross the CTO with the microcatheter (inside the plaque) despite
anchoring balloon.

19. Tip In: retrograde wiring an antegrade microcatheter
• Failure to cross the CTO with the microcatheter (inside the plaque) despite
anchoring balloon.
• What should I do ?
• Antegrade preparation with larger controlled dissection ?
• Exchange the microcatheter (fatigue) ?
• Try to cross again after plaque modification (retrograde Carlino) ?
• Tip In: retrograde wiring an antegrade microcatheter ?

20. Tip In: retrograde wiring an antegrade microcatheter
Antegrade micrcoatheter to cross resistant, fibrotic
proximal cap: Mamba, turnpike spiral…

21. Antegrade microcatheter crossing the lesion
Tip In: retrograde wiring an antegrade microcatheter

22. Tip In: retrograde wiring an antegrade microcatheter

23. Externalisation failure- What next?
• Retrograde crossing with a wire and microcatheter ➔ Externalisation
• Lesion preparation(Ca++, Tortuosities, >20mm)
• Antegrade : plaque modification, ….
• Retrograde : Carlino, CART, …
• Tip In: retrograde wire inside an antegrade microcatheter dedicated
to cross resistant lesion

24. Externalisation failure- What next?
• Retrograde crossing with a wire and microcatheter ➔ Externalisation
• Lesion preparation(Ca++, Tortuosities, >20mm)
• Antegrade : plaque modification, ….
• Retrograde : Carlino, CART, …
• Tip In: retrograde wire inside an antegrade microcatheter dedicated
to cross resistant lesion