This case involves a retrograde approach to treat a chronic total occlusion of the right coronary artery in a 67-year-old male patient with diabetes and prior bypass surgery. A unique collateral channel originating from the sinus node artery connected to the distal RCA. Through a combination of retrograde and antegrade wiring with IVUS guidance, the CTO was crossed using a reverse controlled antegrade and retrograde subintimal tracking technique. A reversed wire technique and stent placement into the posterior descending artery were used to revascularize the entire distal RCA territory while preserving branch vessels. Final angiogram and IVUS confirmed successful revascularization with no complications.

1. Retrograde CTO reverse CART
Setup
Patrick T. Siegrist, MD
Herzzentrum Hirslanden, Zurich, Switzerland
In close collaboration with
Satoru Sumitsuji, MD, FACC
Department of Cardiology for International Education and Research
Osaka University Graduate School of Medicine, Japan

2. Patient data
67-year-old male patient
• Risk factors:
– Diabetes (insulin dependent)
– Dyslipidemia
• Past medical history:
– CAD with CABG 2005:
• LITA – LAD
• SVG – OM branch
• GEA - PDA
– Peripheral vascular disease
• Angina CCS II
• Echo: new inferior hypokinesia, EF 64%

3. ECG

4. SPECT

5. Angiogram LCA
Severe stenoses in the LMT, LAD and
in the OM-branch
LITA-LAD graft patent

6. Angiogram LCA
SVG to OM-branch: occluded

7. Angiogram RCA
The RCA was occluded from the mid segment (J-CTO score: 3)
Unique collateral channel: originating from sinus node artery, connecting to
the distal RCA

8. Patient data
Diagnostic coronary angiogram (2 months earlier)
Native: - chronic total occlusion (CTO) of the right coronary artery
- left main 75-90%
- proximal LAD 75-90%
- OM branch 75-90%
Grafts: - mammary artery graft - LAD patent
- venous graft - OM occluded
- gastroepiploic artery – PDA occluded

9. Angiogram - CT
The RCA was occluded from the mid segment (J-CTO score: 3)
Unique collateral channel: originating from sinus node artery, running along the
left atrium, descending to the AV-groove and then connecting to
the distal RCA.

10. Unique collateral channel

11. Unique collateral channel: originating from sinus node artery, running along the
left atrium, descending to the AV-groove and then connecting to the distal RCA.
Unique collateral channel

12. Procedural course

13. Antegrade approach
An antegrade approach using wires
with increasing stiffness failed.
Rotational fluoroscopy showed an
unnatural course of the wire. The
course of the RCA remained unclear

14. After a Finecross microcatheter was not able to follow the tortuous channel it
was exchanged to the new Caravel. Finally a SUOH guidewire followed by the
Caravel microcatheter could cross the channel and reach the distal CTO entry
point at the RCA bifurcation.
Retrograde approach – channel negotiation

15. Exceptionally difficult wire control
Due to the special anatomical course
of the collateral channel, the heart
beating resulted in a strong pecking
motion of the guidewire-micro-
catheter system.
Adapting to the heart motion, the
wire could be successfully directed
into the CTO (advancement only in
max. distal position).
LAO 36
CRA 15
LAO 50

16. Wire out?
The retrograde wire initially followed what seemed to be the course of the distal
RCA but then suddenly turned and appeared to go out of the heart.
LAO 37
CRA 2

17. Return to antegrade
Since the course of the occluded
segment remained unclear the
antergrade wire was advanced up to
the bifurcation using a knuckle shape
to warrant vessel tracking.
With the reference of the knuckle wire
located just proximal to the
bifurcation, the distal cap of the CTO
could be punctured.
LAO 37
CAU 7
LAO 28
CRA 19

18. Reverse CART
The retrograde and finally the antegrade wire were advanced until they were
overlapping, allowing to perform the reverse controlled antegrade retrograde
tracking (CART) technique in the usual manner.

20. Balloon
Predilation

21. IVUS
To save both main branches (4PD and distal RCA), correct understanding of the
wire course is crucial -> IVUS

25. Reversed wire technique

26. • Originally performed by Dr. Osamu Katoh
• First published by Dr. Tomohiro Kawasaki in Catheter
Cardiovasc Interv. 2008;71:73-6.
• Also Dr. Yoichi Nozaki introduced this technique using the
Crusade double-lumen microcatheter.
Reversed wire technique

27. ① Shape tip curve as usual.
② Create a “hairpin bend” (30-45°) in the floppy part. Use a
double lumen micro-catheter. Main branch wire goes to
the monorail lumen and the Reversed Wire to 2nd lumen.
③ Advance the Reversed Wire system into the Y-connector
while softly folding reversed wire. At the bended point of
reversed wire should be placed around exit port of 2nd
lumen.
Reversed wire technique

28. ～
～
～ ～
～
～
① ② ③ ④
20~30mm

45. Reversed wire

46. Reversed wire

47. Reversed wire

48. Reversed wire

49. Reversed wire
The reversed wire is delivered with a
Crusade double lumen microcatheter.
By rotating the wire tip into the right
direction and slowly pulling the
reversed wire back it could easily find
its way into the PDA.

50. Stent to which branch?

51. Stent to which branch?
To warrant full revascularization, the distal stent has to be placed from RCA
segment 3 into the PDA to seal the plaque and dissection against the vessel wall.

52. Final angiogram
Final angiogram displayed successful revascularization of the right coronary
artery and no significant vascular complications.

53. Final IVUS
Final IVUS showed no remaining dissection, nice stent apposition and a
preserved ostium of the distal RCA (segment 16). Moreover, the unusual proximal
anastomosis of the GEA graft could be detected.
#4PD
#16
#3

54. Summary / Key points
• Unique ipsilateral channel:
SA-artery➡LA➡AV-groove➡distal RCA
• Pecking motion: difficult wire control
Wire advancement only in max. distal position
of the microcatheter
• How to save the whole distal RCA territory:
Reversed wire technique + stenting to PDA
• Unusual GEA anastomosis very close to
the RCA bifurcation
Unclear anatomy during intervention
➡ advance antegrade wire with knuckle

55. Thank you
Patrick T. Siegrist, MD
Interventional Cardiologist
HerzZenztrum Hirslanden Zurich
Switzerland
Email: siegrist@herzzentrum.ch