Abstract
Interventional treatment of chronic total occlusions (CTOs) is nowadays counting on a wide span of procedural possibilities, and retrograde approaches are becoming more and more frequent as they warrant high success rates at the cost of a slightly higher incidence of donor vessel damage. Retrograde lesion crossing needs to be followed by procedural conversion to an antegrade approach to dilate and stent the lesion, and new techniques are being proposed to address this issue and achieve a safer recanalization of the vessel. In this context, we propose novel and simple techniques to antegrade guiding catheter engagement by the retrograde wire, enhancing the chances for procedural success.
Highlights
Chronic total occlusions (CTOs) account for almost 20% of all coronary lesions [1], and indications for CTO treatment have broadened over the last few years since their successful recanalization has been shown to improve angina, quality of life, and ventricular systolic function [2, 3]. e availability of more refined techniques and dedicated materials has increased procedural success up to 90% in experienced hands, according to the latest RCTs, at the cost of an acceptable risk of complications [4]
Procedural conversion implicates a preliminary engagement of the antegrade guiding catheter with the retrograde guidewire, which is usually attempted at the ostium of the occluded artery
Contralateral exchange with the use of an externalization wire (>300 cm in length) is usually the technique of choice for the antegrade conversion of the procedure. e tip of such wires can be gently pushed inside the antegrade guide with the backup support of the retrograde microcatheter, or rather pulled backwards with an antegrade snare [6]. e high tension applied on the retrograde system to pull the retrograde wire out of the antegrade guiding catheter by a snare, as discussed previously, still carries some risk of donor vessel damage, though
Summary
Chronic total occlusions (CTOs) account for almost 20% of all coronary lesions [1], and indications for CTO treatment have broadened over the last few years since their successful recanalization has been shown to improve angina, quality of life, and ventricular systolic function [2, 3]. e availability of more refined techniques and dedicated materials has increased procedural success up to 90% in experienced hands, according to the latest RCTs, at the cost of an acceptable risk of complications [4]. Procedural conversion implicates a preliminary engagement of the antegrade guiding catheter with the retrograde guidewire, which is usually attempted at the ostium of the occluded artery. Such attempts are not always successful, though, since their two tips need to be coaxial for the wire to enter the guide, while an eccentric exit point from the occlusion and heart cycle-related movements may interfere with their alignment. E catch-it maneuver we described can be performed in the aortic arch, in the ascending aorta or in the descending aorta according to patient-specific anatomical conditions, in order to achieve the best position for the alignment of the antegrade catheter with the retrograde wire (Figures 2 and 3)
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