Controlled Antegrade And Retrograde Subintimal Tracking Research Articles

Controlled antegrade and retrograde subintimal tracking (CART) for recanalisation of chronic total occlusions.

Controlled antegrade and retrograde subintimal tracking (CART) is rarely performed in contemporary chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We aimed to analyse the indications, procedural characteristics, and outcomes of CART at a high-volume CTO programme. We included all patients undergoing a retrograde CTO PCI in which CART was performed at our institution between January 2019 and November 2023. The primary endpoint was technical success. Of 1,582 CTO PCI, the retrograde approach was performed in 603 procedures (38.1%), and CART was used in 45 cases (7.5%). The mean age was 69.1±10.3 years, 93.3% were male, and prior coronary artery bypass graft surgery was present in 68.9%. The most common target CTO vessel was the right coronary artery (48.9%). Anatomical complexity was high (Multicentre CTO Registry of Japan [J-CTO] score of 3.6±0.9). The most common collateral used for CART was a saphenous vein graft (62.2%). Advanced calcium modification was required in 15.6% of cases. CART was successful in 73.3%. Technical and procedural success was 82.2%. Coronary perforation was diagnosed in 4 subjects (8.9%), but only 1 patient (2.2%) suffered tamponade and required pericardiocentesis. No other in-hospital major adverse cardiac events were diagnosed. CART is a useful technique in selected, very complex CTOs tackled with the retrograde approach. Success rates were high, while complication rates were low, considering the high anatomical complexity and baseline patient risk.

D-52 | Role of controlled antegrade and retrograde subintimal tracking (CART) in contemporary chronic total occlusion recanalization

D-52 | Role of controlled antegrade and retrograde subintimal tracking (CART) in contemporary chronic total occlusion recanalization

From reverse CART to antegrade wire access: a guide to externalisation, tip-in, rendezvous, and snaring from the APCTO club: Reverse CART to antegrade access.

We at the Asia Pacific Chronic Total Occlusion (APCTO) club, provide this review to address the gap between reverse controlled antegrade and retrograde subintimal tracking (CART) and antegrade wire access. We describe the usual method for wire externalisation. We then address how to deal with failure to wire the proximal part of the chronic total occlusion (CTO) vessel or the guiding catheter. After successful antegrade guiding catheter wiring, we address the problem of failing to cross the CTO body with the retrograde microcatheter and we recommend the use of a retrograde small balloon, reversion to traditional CART, retrograde knuckle wiring into the subintimal space and antegrade scratch and go, and external cap crush. We also propose rendezvous type tip-in and describe the way to do this to overcome problems. In conclusion, we review and make recommendations for methods to gain antegrade wire access after successful reverse CART. We have addressed each failure mode in detail covering the different options, balancing risks and success rates. Our recommendations focus upon safety first and ease of use. We hope this work will help all retrograde operators to further improve the safety, efficacy, and success rates of their retrograde procedures.

Predictors of Failure of Retrograde Approach for Percutaneous Intervention of Coronary Chronic Total Occlusion: A Single-Center Experience

Objective: The aim of the study is to assess the predictors of failure of percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) lesions using a retrograde approach. Methods: The present study retrospectively enrolled all 211 patients who underwent retrograde CTO PCI from January 2009 to December 2015 at Shanghai Institute of Cardiovascular Disease. Multivariate Cox regression analysis was used to assess potential predictors of retrograde CTO PCI failure including sex, vascular access site, sheath size, prior PCI, prior coronary artery bypass grafting, history of myocardial infarction, target vessel of CTO, J-CTO score, retrograde wire crossing collaterals, and reverse controlled antegrade and retrograde subintimal tracking (CART) use. Results: Of the 211 patients studied, retrograde CTO PCI was successful in 115 (54.5%) patients, and in an additional 46 (21.8%) with an antegrade approach after retrograde failure. For the 50 (23.7%) patients who failed both retrograde and antegrade approaches, the most common (50% [25/50]) reason was inability to cross collaterals with the retrograde wire. This group of patients had fewer instances of a prior PCI (P

Procedure failure of chronic total occlusion percutaneous coronary intervention in an algorithm driven contemporary Asia-Pacific Chronic Total Occlusion Club (APCTO Club) multicenter registry.

With the evolution of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) technique and equipment, the success rate of CTO PCI has improved over the years. We examined the failed cases in this expert registry and looked at the mode of failure. In 2016, consecutive CTO PCI performed by eight high volume CTO with an agreed CTO algorithm were examined in a registry. There was a total of 485 patients with 497 CTOs were treated with technical and procedural success rates of 93.8% and 89.9%, respectively. The mean J-CTO score was 2.9 ± 1.2. The main mode of failure in cases with only antegrade attempt was inability to wire to true lumen despite advanced antegrade wiring technique for example, parallel wiring or IVUS guided wiring (10 out of 11 cases). The mode of failure in retrograde attempt was: 30% was due to inability to wire the collateral channel; 30% was due to failed reverse controlled antegrade and retrograde subintimal tracking (CART); 30% was due to inability to cross CTO by retrograde microcatheter. Four cases were terminated prematurely due to procedure complications. Similar to previous reported studies, primary failure mode of only antegrade attempt was inability to wire to true lumen. However, contrary to other registries where failure to cross the retrograde channel with wire was the predominant failure mode, the retrograde failure mode was equally divided between failure to cross the channel with wire, failure to do reverse CART, and failure to cross the CTO with the microcatheter.

Usefulness and Safety of a Novel Modification of the Retrograde Approach for the Long Tortuous Chronic Total Occlusion of Coronary Arteries.

The aim of this study was to evaluate the feasibility and efficacy of the Guidezilla guide extension catheter in a reverse controlled antegrade and retrograde subintimal tracking (CART) technique for chronic total occlusion (CTO) recanalization.We retrospectively collected 80 CTO cases using reverse CART technology from January 2015 to October 2015 and 20 CTO cases using Guidezilla reverse-CART technology from October 2015 to March 2016. Guidezilla was applied in cases when it was difficult to advance a retro-guidewire through an occlusion segment into the antegrade guide catheter.The Guidezilla group had more cases with an occlusion longer > 20 mm (100.0% versus 72.5%, P = 0.005) and "bending > 45°" (90.0% versus 63.7%, P = 0.029) than the non-Guidezilla group, while the non-Guidezilla group had more retry lesions (25.0% versus 63.8%, P = 0.002). The septal collateral channel was the preferred choice for retro-recanalization in both groups (90.0% in Guidezilla group and 68.8% in non-Guidezilla group). All cases in the Guidezilla group achieved technical success with a TIMI 3 flow in the distal true lumen (100.0% versus 75.0% in non-Guidezilla group, P = 0.010). Cardiac tamponade and perforation in the epicardial artery was observed in 1 case each in the Guidezilla group. In the non-Guidezilla group, 19 complications occurred during the PCI procedure. No target vessel revascularization or in-hospital death occurred in either group.CTO lesions using the Guidezilla guide extension catheter to facilitate entry to an antegrade catheter in reverse CART technology is convenient and safe with a high success rate.

Current Retrograde Approach Is Unfavorable to Long-Term Clinical Outcomes after Percutaneous Coronary Intervention for Chronic Total Occlusion.

Surgeons currently use two different wire-based approaches to recanalize coronary chronic total occlusion (CTO): antegrade and retrograde. It has been demonstrated that the retrograde approach has improved the procedural success rate, but it remains unclear whether the retrograde approach is better than the antegrade approach for the long term. In this study, we enrolled a total of 187 patients with a diagnosis of CTOs. We evaluated the baseline characteristics of these patients and performed percutaneous coronary intervention to treat their problems by using either antegrade or retrograde approaches and different techniques in both groups. In the antegrade approach, we used three techniques: single wire, parallel wire, and side branch. The techniques in retrograde included kissing wire, controlled antegrade and retrograde subintimal tracking (CART), and reverse CART. We found that the antegrade and retrograde groups had similar baseline characteristics, with a few minor differences. Most importantly, we found that within 1 yr of the recanalizing procedure, the restenosis rate and major adverse cardiac event rate of the retrograde group were significantly higher compared to the antegrade group. We conclude that the retrograde approach may not be as beneficial as the antegrade approach for long-term clinical outcomes.

TCT-205 Mid-term angiographic and clinical outcomes of controlled antegrade and retrograde subintimal tracking (CART) or reverse CART technique for the recanalization of chronic total occlusions

TCT-205 Mid-term angiographic and clinical outcomes of controlled antegrade and retrograde subintimal tracking (CART) or reverse CART technique for the recanalization of chronic total occlusions

Approach for Chronic Total Occlusion With Intravascular Ultrasound–Guided Reverse Controlled Antegrade and Retrograde Tracking Technique: Single Center Experience

Controlled antegrade and retrograde subintimal tracking (CART) or reverse CART techniques is the final step for percutaneous revascularization of coronary chronic total occlusion (CTO), but it still represents technical challenges and risk in interventional procedures. Our purpose was to utilize intravascular ultrasound (IVUS)-guided reverse CART approach for percutaneous revascularization of CTO in our heart center, focusing on its safety, efficacy, and latest technical developments. From November 2006 to November 2012, 49 patients with CTO failed to antegrade and/or retrograde percutaneous revascularization of CTO from true lumen to true lumen were enrolled in and underwent IVUS guided reverse CART approach. The mean J-CTO score of cases was 2.5. IVUS guidance was successfully implemented in 95.9%; IVUS identified that 61.7% of retrograde wires were located at intimal space, and 59.5% of antegrade wires were located at subintimal space. A Corsair channel dilator was used in 77.6% of cases. The success rates of technique and procedure were 95.9% and 93.9%, respectively; the technical minor complications were observed in 10.2% of cases, without significant clinic outcomes; 2.0% of cases occurred with a major adverse cardiac event of non-ST-elevation myocardial infarction; and no case occurred with target vessel revascularization or death. The mean length of stent implanted in a single CTO vessel was 51.3 mm. No patient appeared with radiation dermatitis and contrast-induced rise of creatinine. IVUS guided reverse CART approach is effective and safe for percutaneous revascularization of complex CTO, with a high success and a low complication rate. It is feasible to develop this approach for percutaneous revascularization of complex CTO. However, suitable case selection and lately device handling by experienced operators are the crucial points of success.

Delayed DES endothelialisation after subintimal recanalization of chronic of total occlusion: observation by optical coherence tomography

Background: Chronic total occlusions (CTO) interventions using reverse CART (controlled antegrade and retrograde subintimal tracking) is one of the most challenging procedures in the field of interventional cardiology. Successful CTO treatment is able to increase left ventricular function, exercise capacity and reduction of mortality. Up to date no adequate information on stent strut endothelialisation following CTO treatment is available. In particular, the duration of dual antiplatelet therapy (DAPT) following CTO treatment remains an issue of debate. Following successful CTO treatment, patients are at risk for both increased risk of restenosis as well as stent thrombosis. DAPT is able to sufficient reduce frequency of stent thrombosis, but keeps an increased risk of major bleeding in case of unnecessarily prolonged ingestion. Intracoronary optical coherence tomography (OCT) is a novel invasive diagnostic method, which is able to precisely analyse stent strut endothelialisation. The aim of this study is to analyse stent strut endothelialisation after CTO treatment in comparison with OCT analysis after DES in non-CTO lesions. We tested the hypothesis, that OCT detects delayed endothelialisation after CTO treatment compared to standard DES PCI. Methods and results: We performed diagnostic OCT measurements during invasive follow-up following successful CTO treatment as well as DES treatment of complex lesions. Patients had been treated with 2nd generation DES (Xience V, Promus, Endeavor Resolute). We performed OCT analysis of n = 14 lesions following CTO-treatment and n=13 lesions after standard DES treatment. Mean time point of OCT analysis was 7.8 months and 6.5 months, respectively (p=0.83). In all cases, no acute coronary syndromes or severe bleeding under DAPT were detected afterwards. Stent struts (in total n=7067) were analysed and classified by OCT according to previously described methods and criteria (CTO recanalization vs. direct implanted DES; mean ± SEM): covered struts: 81.65±2.9% vs. 97.34±0.78%, p<0.0001; protruding/uncovered struts: 10.1±1.7% vs. 1.4±0.4%, p<0.0001; malapposed/uncovered struts: 7.9±2.0% vs. 1.3±0.5%, p<0.001.2 Every fifths OCT image was analysed. No MACE events were found in this series. Conclusion: We describe delayed stent strut endothelialisation after CTO treatment. Subintimal tracking during antegrade as well as retrograde wire advancement could be responsible for our findings. Our results suggest an urgent need to extend the DAPT after CTO treatment to reduce the risk of late stent thrombosis.

A novel technique of chronic total occlusion retrograde wire crossing by wiring into the antegrade microcatheter

We described a novel transradial retrograde wiring technique to treat chronic total occlusion (CTO) of the left anterior descending artery. When both retrograde wire and kissing wire technique failed to cross the CTO lesion, an antegrade microcatheter was placed in the CTO lesion. Then, a retrograde wire was manipulated into the antegrade microcatheter and subsequently exchanged and wire externalized. This technique appears to be feasible and safe alternative for retrograde wire crossing of the CTO lesion. It is a less traumatic modified version of controlled antegrade and retrograde subintimal tracking (CART) technique that can be attempted before embarking on CART or reverse CART strategy.

The Efficacy of a Bilateral Approach for Treating Lesions With Chronic Total Occlusions: The CART (Controlled Antegrade and Retrograde subintimal Tracking) Registry

The aim of this study was to evaluate the safety and feasibility of a new concept for chronic total occlusion (CTO) recanalization-using a bilateral approach that utilizes a Controlled Antegrade and Retrograde subintimal Tracking (CART) technique. Successful percutaneous recanalization of coronary CTOs results in improved long-term outcomes. The recanalization of CTOs in native coronary arteries no doubt represents one of the most technically challenging of interventional procedures. A total of 224 consecutive patients (mean age 61 +/- 9 years; 86.2% men) were enrolled in this prospective multicenter registry. This technique combines the simultaneous use of antegrade and retrograde approaches. A subintimal dissection is created in both antegrade and retrograde fashion, thereby limiting the extension of the subintimal dissection within the CTO portion. Of 224 CTO lesions (>3 months in duration) undergoing attempted recanalization using the CART technique, 145 cases (64.7%) had undergone previous CTO recanalization attempts. The success rates of crossing in a retrograde fashion with a wire and a balloon were 87.9% and 79.9%, respectively. The overall technical and procedural success rates achieved in this registry were 92.4% and 90.6%, respectively. A bilateral approach for CTO lesions using the CART technique is feasible, safe, and has a higher success rate than previous approaches. These results indicate that a bilateral technique can solve a major dilemma that commonly affects CTO procedures.