A Novel, Modified Reverse Controlled Antegrade and Retrograde Subintimal Tracking Technique for Bypassing the Calcified Proximal Cap of Coronary Total Occlusions

Abstract

Antegrade crossing is the most common approach to chronic total occlusions (CTOs). However, it is sometimes difficult to penetrate the proximal hard cap with guidewires, especially in the case of CTOs of anomalous coronary arteries because of a lack of support. Herein, we describe a novel, modified reverse controlled antegrade and retrograde subintimal tracking (CART) technique in which the dissection reentry was intentionally created in the proximal segment of the vessel, not within the occluded segment, using retrograde guidewire and the aid of an antegrade balloon. This technique facilitated retrograde crossing of CTOs by avoiding the proximal hard cap and may provide a viable option for patients in which conventional reverse CART is not possible.

Knuckle wire technique in percutaneous coronary intervention of chronic total occlusion

“…Therefore, in contemporary chronic total occlusion (CTO) intervention scenarios (Figure 2), the knuckle wire is used mostly as a last resort only to create subintimal dissection, and reentry is assisted by CrossBoss™ catheter-Stingray™ LP system (Boston Scientific Corp., Marlborough, MA, USA), controlled antegrade and retrograde tracking (CART), or reverse CART 4,5 . The knuckle technique, when performed antegrade or retrograde, helps in long occlusions, especially with calcification, to maintain the guidewire position in the subintimal space within the vessel architecture [6][7][8][9] .…”