Georgios Sianos, MD, PhD, FESCAristotle University

AHEPA University Hospital

Thessaloniki, Greece

A’ Cardiology DepartmentAHEPA University Hospital

Aristotle Universityof Thessaloniki

RETROGRADE STEP BY STEP APPROACH

CART techniqueThe novelty in 2005

Targeted collateral crossing

Septal collateral dilatation (1.25-1.5 mm long OTW balloons at max 4 atm)

Connection of the subintimal spaces

CART technique

KATOH 2005

The Continuum of CTO PCI

Dissection Reentry

Antegrade

Retrograde

Adoption of only 1 or 2 of these limbs will limit the patients that can be treated on the basis of coronary anatomy

Plan each step…

RETROGRADE AT A GLANCE

SPRAAT J.

Septal surfing technique

Fielder FC, SION, SION blue

Selective contrast injection

Microcatheter inner lumen size matters

SION black, Fielder XT-R, SUOH

Wire collateral crossing

CC crossing-”septal surfing”

SionBlack on CaravelFielder XT-R on Caravel

CC crossing-Tip Injection

Microcatheter Collateral crossing

Microcatheter inner lumen matters

Microcatheter selection

Corsair, Caravel, Finecross, Turnpike, Turnpike LP

Solving MC crossing problems

Choose guiding catheters with good backup support

Change the failing MC

Ballooning by small balloon with low pressure

Balloon anchoring

Select another retrograde channel

CTO lesion crossing

Retrograde Wire Escalation (RWE)

Retrograde wire crossing

Retrograde Dissection and Reentry (RDR)

CART

Reverse CART

Stent facilitated

Guideliner facilitated

Guide extension facilitated

RetrogradeDissectionRe-entry

(RDR)

RetrogradeWire Escalation

(RWE)

AntegradeDissectionRe-entry

(ADR)

AntegradeWire Escalation

(AWE)

CTO CROSSING`Wire Options To Crossing CTOs

Courtesy J Spraat

Milestones in CTO wire TechnologiesSianos et al. BMC Cardiovascular Disorders (2016) 16:33

Sequence of Wire Selection in Contemporary CTO Techniques

(Antegrade and Retrograde)

Soft (<1gf)-tapered-polymeric-composite core GWs (Fielder XT-A/R) for soft tissue tracking (passive wire control)

Intermediate stiff (2-6 gf)-tapered-composite core GWs (GAIA family) for hard tissue tracking (active wire control)

Stiff (>9gf)-tapered GWs (Confianza pro / Progress 200T) for calcified tissue penetration

Retrograde wire externalization

MC and wire in the antegrade GC

Dedicated wires (RG3)

Snares

Tip in methods

Male 55 years old Presented with unstable angina Risk Factors:

- Dyslipidemia - Ex-smoker- ID diabetes- COPD

Non Invasive testing.- Exercise test positive for myocardial ischemia- 2D ECHO: hypokinesia of inferior wall, EF 55%

Patient refused CABGSYNTAX score 21.5

CASE

Diagnostic coronary angiography

Collateral crossed, SION blue Lesion crossing, Fielder FC

Trapping technique, Corsair advancement

FINAL RESULT

Male 62 years old Presented with stable angina class III Risk Factors:

- Dyslipidemia - Ex-smoker- ID diabetes

Normal LV function EF 65%CTO LAD Previous failed attempt to recanalise the LAD

CASE

Diagnostic coronary angiography

Short antegrade attempt

Corsair and SION wireSelective contrast injection

Corsair and GAIA FIRST

Finecross antegrade, Corsair retrograde over RG3

FINAL RESULT AFTER BVS IMPLANTATION

81 Y, FEMALEAP CLASS IIIHT, HLP, DM

CASE

DIAGNOSTIC ANGIOGRAMCOLLATERAL TIP INJECTION

AFTER LAD TREATMENT

COLLATERAL CROSSING

SION WIRE

PERIPHERAL TIP INJECTION

FAILED RETROGRADE WIRE CROSSING

RWE X-CART TECHNIQUE

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

FINAL RESULT

CASE

40 Y, MALEAP CLASS IIIHT, HLP, DMPREVIOUS CABG…

Diagnostic Coronary Angiography

Bilateral contrast injection

ANTEGRADE APPROACH

FINECROSS / GAIA FIRST

PARALLEL WIRINGGAIA SECOND

ANTEGRADE APPROACH

Antegrade wiring

Switch to retrograde after 10 min of radiation radiation time

RETROGRADE APPROACH

CORSAIR SION SELECTIVE CONTRAST INJECTION

RETROGRADE APPROACH

SELECTIVE CONTRAST INJECTION

RETROGRADE APPROACH

CORSAIR EXCHANGED TO FINECROSS

SELECTIVE CONTRAST INJECTION

RETROGRADE APPROACH

GUIDELINER ASSISTED XCART

GAIA SECOND

GUIDELINER ENGAGMENT

Trapping technique, retrograde MC advancement

FINAR RESULT

Final result

EuroIntervention. 2012 May 15;8(1):139-45

The retrograde technique represents a breakthrough in CTO recanalisation with success rates exceeding 90% in complex CTOs and it has comparable complication rates with contemporary antegrade techniques.

Current evidence suggests that they should be reserved for second attempts after antegrade failure, or as strategies of choice in very complex CTOs where the expected antegradesuccess rate is <50%.

CONSENSUS ON THE RETROGRADE APPROACH

Recent trends in practice suggest implementation of the retrograde techniques after short antegrade failures (aimed at reducing procedure duration, contrast consumption and radiation exposure), but until more data become available this approach should be reserved for very experienced operators.

Retrograde techniques should be reserved for very experienced antegrade operators (>300 CTOs & >50 per year).

A minimum of 50 retrograde procedures (25 as second operator and 25 as first under supervision) are required before a cardiologist becomes an independent retrograde operator.

CONSENSUS ON THE RETROGRADE APPROACH

Think first retrograde when…

Truly aorto-ostial occlusionsGood interventional collateralsProximal cap - ambiguous anatomy or not crossed

antegradeLong lesion with undefined CTO coursePoor distal vessel opacificationVessel reconstitutes at a distal bifurcationRepeat attempts Tandem CTOs Post GABG patientsContrast Sparing

But above all when you are well trained…….

Cath LAB set up trained supporting personnel (assistants, technicians & nurses) Dual catheter injections Vigilant ACT monitoring (Cave donor artery

complications) CTO TOOLBOX

Long sheaths GC (short/end) GC extensions Wires full spectrum and dedicated for channel tracking

(SION family, XTR) and externalisation (RG3) Microcatheters (Corsair, Finecross) Syringes for tip injections Dual lumen MC ( Twinpass, Crusade) Snares Coils

IMAGING (IVUS, MSCT)

Retrograde Set up

CONCLUSION

Retrograde techniques are well established and standardised.

Center organisation and operator experience are of paramount importance for the effective and safe application of these techniques in routine practice.