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

A case of chronic total occlusion in popliteal artery recanalized by double snare piercing technique

BackgroundAlthough majority of cases with chronic total occlusion (CTO) in femoro-popliteal lesion were treated with antegrade approach only, some lesions require alternative approach due to its complexity. Bi-directional approach is useful on endovascular therapy (EVT) for CTO; however guidewire passage through the lesion is impossible in some challenging cases. The present case shows a successful re-entry technique utilizing two snare catheters from an antegrade and retrograde access site (double snare piecing technique).Case presentationA 79-year-old woman with right leg intermittent claudication (Rutherford category IV), who had undergone unsuccessful EVT for popliteal CTO, required another EVT for the worsening symptom. Following the failed conventional crossing technique (wire knuckle technique, intravascular-ultrasound-guided wiring, and controlled antegrade and retrograde subintimal tracking technique), two snare catheters were placed and the snare loops were pierced by a puncture needle percutaneously. After an 0.014 wire was inserted into the needle, the needle was withdrawn. The wire was pulled from the retrograde side and was externalized. Then, the antegrade snare catheter was pulled and externalized, to make the wire across the lesion. After that, a microcatheter was advanced along the externalized wire from the retrograde side and cross the lesion. The wire was replaced with a new wire, which completely created pull-through system. After the hemostasis by balloon inflation and lesion preparation, this procedure was completed with an endoluminal-covered stent and two inter-woven stents. The re-entry site was covered by the inter-woven stent. Her symptoms improved after the procedure, and the lesion has not developed restenosis at 2-years follow-up.ConclusionsThis re-entry technique of puncturing two snare loops (double snare piercing technique) might be effective for achieving successful passage through challenging femoropopliteal CTO cases.

Role of the retrograde Carlino technique for chronic total occlusion percutaneous coronary intervention.

There is scarce data on the outcomes of the Carlino technique for chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We aimed to investigate the indications and outcomes of the Carlino technique as performed in the context of the retrograde approach. We pooled CTO PCI cases where a retrograde Carlino technique was performed from high-volume operators at four centers. The Carlino technique was characterized according to its indication (achieving plaque/cap modification, clarifying microcatheter location within the vessel, resolving distal cap ambiguity) and was considered successful when it led to the desired outcome. A total of 43 patients were included. Occlusion complexity was very high (mean J-CTO score 3.3 ± 0.8). The two most common indications were understanding the anatomy of the occlusion and clarifying gear location (37.2%) and impenetrable distal cap (34.9%). The Carlino technique was successful in 88.4% of cases. Overall technical and procedural success was 86.0%. The most common successful crossing technique was reverse controlled antegrade and retrograde subintimal tracking (70.3%). No complications were attributed to the Carlino technique. We observed a high success rate of the retrograde Carlino technique, as well as overall technical and procedural success rates. No Carlino technique-related complications were observed. Additional data from larger registries are warranted to further confirm the safety and efficacy of this technique.

Outcomes of contemporary versus conventional reverse controlled and antegrade and retrograde subintimal tracking in chronic total occlusion revascularization

Chronic total occlusion (CTO) lesions remain technically challenging for percutaneous coronary intervention (PCI). The introduction of a retrograde approach has allowed marked improvement in the success rate of CTO recanalization. Reverse controlled anterograde and retrograde sub-intimal tracking (reverse CART) is the predominant retrograde wire crossing technique and can be broadly classified into three categories: (1) conventional (2) contemporary and (3) extended. The present study aimed to compare the safety and efficacy of conventional and contemporary reverse CART techniques. From March 2015 to May 2020, 303 patients achieving successful retrograde guidewire crossing with conventional or contemporary reverse CART during CTO PCI were included in the study. The patient characteristics, procedural outcomes and in-hospital and 1-year clinical events were compared between the conventional and contemporary groups. The distributions of the baseline and angiographic characteristics were similar in both study arms, except the CTO lesions of the conventional group were more complex, as reflected by borderline significantly higher mean J-CTO scores (3.4 ± 0.7 vs. 3.3 ± 0.8; p= 0.059). Recanalization using contemporary reverse CART was associated with a short procedure time (189.8 ± 44.4 vs. 181.7 ± 37.3 min; p= 0.044) and decreased procedural complications, particularly target vessel perforation (3.6% vs. 0.6%; p= 0.063) and major side-branch occlusion (36.7% vs. 28.0%; p= 0.051). Technical and procedural success and the in-hospital and 1-year outcomes were not significantly different between the groups. Contemporary reverse CART is associated with favorably high efficiency and low-complication rates and carries a comparable success rate and 1-year clinical outcomes as conventional reverse CART.

Angiographical coronary artery calcification predicts antegrade guidewire crossing during percutaneous coronary intervention of chronic total occlusion

Background: Coronary artery calcification (CAC) is a predictor of failed revascularization in Chronic Total Occlusion (CTO) Percutaneous Coronary Intervention (PCI). However, CTO PCI operators believe that angiographical CAC shows promise as a landmark in the manipulation of antegrade guidewire crossing. We aimed to identify the relationship between angiographical CAC and successful antegrade guidewire crossing in CTO PCI. Methods and Findings: This single-center, retrospective, observational study enrolled 48 consecutive patients who underwent Coronary Computed Tomography Angiography (CCTA) before PCI for CTO. They were divided, according to the level of antegrade guidewire crossing success, into the success (≤ 30 min; n=25, 50%) and unsuccess (>30 min; n=25, 50%) groups. All the CCTA and coronary angiographic findings obtained before PCI were analyzed. We assessed the relationship between angiographical CAC and successful antegrade guidewire crossing and other factors associated with it. The baseline characteristics were similar between the groups. Angiographical CAC was more frequently observed in the success group than in the unsuccess group (68% vs. 24%, p=0.080). There were no statistically significant differences in the CTO entry morphology, bridging collateral, vessel bending, distal reference diameter, occlusion length, and calcification severity between the groups. In the multivariable analysis, angiographical CAC in the CTO lesion predicted successful antegrade guidewire crossing within 30 min (odds ratio=0.043, 95% confidence interval=0.003–0.614, p=0.006). Conclusion: Angiographical CAC may be a promising landmark for antegrade wire manipulation in patients with CTO. Abbreviations: CAC: Coronary Artery Calcification; CAG: Coronary Angiography; CART: Controlled Antegrade and Retrograde Subintimal Tracking; CCTA: Coronary Computed Tomography Angiography; CTO: Chronic Total Occlusion; IVUS: Intravascular Ultrasound; J-CTO: Multicenter CTO Registry of Japan; LAD: Left Descending Artery; LCX: Left Circumflex Artery; PCI: Percutaneous Coronary Intervention; RCA: Right Coronary Artery; TIMI: Thrombolysis in Myocardial Infarction

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.

Intravascular ultrasound-guided "extended" reverse controlled antegrade and retrograde subintimal tracking technique using a cutting balloon for recanalizing chronic coronary total occlusion with a side branch.

Intravascular ultrasound-guided "extended" reverse controlled antegrade and retrograde subintimal tracking technique using a cutting balloon for recanalizing chronic coronary total occlusion with a side branch.

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

TCTAP C-197 Successfully Endovascular Therapy for Bilateral Common Iliac Vein Chronic Total Occlusion: Antegrade Revascularization First for Contralateral Controlled Antegrade and Retrograde Subintimal Tracking Revascularization

### Patient Initials or Identifier Number Miss C ### Relevant Clinical History and Physical Exam An 81-year-old female patient presented bilateral lower limbs swelling for one month. She has a past medical history of paroxysmal atrial fibrillation with the slow ventricular response with permanent

Sealed Rupture of the Superficial Femoral Artery After Endovascular Treatment Via the Controlled Antegrade and Retrograde Subintimal Tracking Technique for Chronic Total Occlusion

A 73-year-old man presented with intermittent claudication of the right lower limb. His angiogram showed a long-segment chronic total occlusion (CTO) in the right superficial femoral artery (SFA) ([Figure 1A][1]). A 6-F guiding sheath was inserted into the right common femoral artery via the

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.

Successful contemporary reverse controlled antegrade and retrograde subintimal tracking without contrast medium: a case report

BackgroundContrast-induced acute kidney injury is one of the common adverse events related to percutaneous coronary intervention and a predictor for worse outcome. In the setting of percutaneous coronary intervention for chronic total occlusion, large amounts of contrast medium, more than 200–400 mL, are generally injected. A higher dose of contrast medium causes contrast-induced acute kidney injury more frequently. Therefore, patients who undergo chronic total occlusion-percutaneous coronary intervention are at risk for contrast-induced acute kidney injury.Case presentationWe present the case of a 77-year-old Japanese man with post-acute myocardial infarction angina pectoris, heart failure, and chronic kidney disease who underwent percutaneous coronary intervention for chronic total occlusion in his right coronary artery. In the procedure, the retrograde wire was a visible penetration mark that made contrast medium unnecessary. Contemporary reverse controlled antegrade and retrograde subintimal tracking was successfully achieved and stents were implanted without contrast medium. Contrast medium was injected two times after stent implantation to confirm coronary flow and no perforation. The total amount of contrast medium was only 8 mL for chronic total occlusion-percutaneous coronary intervention.ConclusionChronic total occlusion-percutaneous coronary intervention with contemporary reverse controlled antegrade and retrograde subintimal tracking without contrast medium may be safe and feasible in selected patients.

Active greeting technique: a mother-and-child catheter based technique to facilitate retrograde wire externalization in recanalization of coronary chronic total occlusion

Although retrograde approach has greatly improved the success rate of percutaneous coronary intervention (PCI) for coronary chronic total occlusion (CTO), retrograde wire externalization still remains challenging and time-consuming in some cases. Cases utilizing “Active Greeting Technique (AGT)”, a mother-and-child catheter based technique to facilitate retrograde wire externalization, were extracted from Chronic Total Occlusion Club, China (CTOCC) database. AGT was performed by deep intubation a mother-and-child catheter (Guidezilla™ extension, 4 or 5 Fr inner catheter, and etc.) in combination with either reverse controlled antegrade or retrograde subintimal tracking (CART) technique or retrograde wire crossing technique. A total of 111 patients with 112 CTO lesions treated with this technique were retrospectively analyzed. Reverse CART technique and retrograde wire crossing technique were performed in 90.2% and 9.8% of all procedures. The utilization of Guidezilla™ extension, 4 Fr, and 5 Fr inner catheter accounted for 94.6%, 3.6%, and 1.8%, respectively. Externalization of retrograde wire was successful in all cases. No procedural complications were adjudicated to AGT. Complications independent of AGT included two target vessel perforations and two collateral perforations. No in-hospital major adverse cardiac events were found. AGT is a feasible and safe technique that facilitates retrograde wire externalization.

TCTAP C-235 Successful Endovascular Treatment of Chronic Total Occlusion of Below-the-knee Using Reverse Controlled Antegrade and Retrograde Subintimal Tracking (Reverse CART) Technique

### Patient initials or identifier number LDS, 21292673 ### Relevant clinical history and physical exam A 57 years-old man with a history of hypertension, DM and hemodialysis admitted to our hospital complaining Rt. His 2nd toe discoloration with resting pain, a Rutherford classification of grade

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.

Impact of the Intracoronary Rendezvous technique on coronary angioplasty for chronic total occlusion.

The Rendezvous technique, which requires bidirectional wiring, is one of the useful methods for improving the success rate of recanalization for chronic total occlusion (CTO) in the field of peripheral intervention. Recently, advanced new devices for percutaneous coronary intervention have enabled us to perform the Rendezvous technique for peripheral as well as for coronary CTO lesions. We used the Intracoronary Rendezvous technique to perform angioplasty for coronary CTO. "Intracoronary Rendezvous" means that Rendezvous was achieved within the CTO lesion. From March 2009 to November 2015, 189 patients underwent CTO angioplasty at our institute, and we treated 10 patients with the Intracoronary Rendezvous technique. This technique involves crossing the Gaia series guidewire to the contralateral Corsair microcatheter located inside the plaque of CTO lesions. The majority of the CTO sites examined were in the proximal RCA (60%). Lesion length of the occlusion was relatively long (64.4±12.2mm). Using the biplane imaging system, we were able to control the Gaia guidewires in a specific direction. Furthermore, if the antegrade and retrograde wires can be advanced into contiguous space inside the CTO lesion, we intentionally entered either wire into the contralateral Corsair microcatheter, followed by successful CTO crossing. CTO recanalization was completed for all patients without controlled antegrade retrograde subintimal tracking (CART) or reverse CART. No major complications occurred during hospitalization. These results indicate that the Rendezvous technique, assisted by new devices and a biplane imaging system, represents one of the primary options to achieve successful coronary CTO recanalization.

Outcomes of Endovascular Therapy With the Controlled Antegrade Retrograde Subintimal Tracking (CART) or Reverse CART Technique for Long Infrainguinal Occlusions

Purpose: To compare the safety, efficacy, and clinical outcomes associated with the controlled antegrade retrograde subintimal tracking (CART) or reverse CART (r-CART) technique to the conventional retrograde approach in the treatment of patients with long infrainguinal occlusions. Methods: From May 2008 to April 2014, 121 patients failed antegrade recanalization and underwent a retrograde approach to recanalize long infrainguinal occlusions. Patients who underwent successful endovascular therapy (EVT) by the conventional retrograde approach (CRA group) were compared to patients who had successful EVT using the CART/r-CART technique (CART group) after failure of a bidirectional approach. The efficacy, safety, vessel patency, and other clinical outcomes were compared between the groups. Results: Fifty-eight patients (mean age 71.6±12.2 years; 32 men) underwent successful EVT (47.9%, 58/121) using the conventional retrograde approach (CRA group), while 44 patients (mean age 70.8±11.1 years; 31 men) among the 50 patients who underwent the CART/r-CART technique were successfully treated (88.0%, 44/50). Both groups had similar average occlusion lengths and gained 100% immediate hemodynamic success after EVT. There was no significant difference between the groups regarding procedure-related complications. During follow-up, 28 patients died (p=0.380), but there were no differences in the rates of major (p=0.279) or minor amputation (p=0.417) between the groups. There was no difference in the 2-year primary patency (31% vs 24%, p=0.686), assisted primary patency (66% vs 76%, p=0.251), target vessel revascularization (65% vs 54%, p=0.845), or sustained clinical success (52% vs 46%, p=0.995) rates between the CRA and CART groups, respectively. Conclusion: Based on acceptable safety, efficacy, and follow-up results in this study, the CART/r-CART technique can salvage patients with long peripheral occlusions after failure of the conventional antegrade or retrograde approach.

Retrograde Coronary Chronic Total Occlusion Intervention Using a Novel Reverse Controlled Antegrade and Retrograde Subintimal Tracking.

Chronic total occlusion (CTO) is a frequent finding in patients with coronary artery disease and when clinically indicated, remains one of the most challenging subsets for intervention. Although successful recanalization rates of CTO have remained suboptimal in percutaneous coronary intervention, evolving techniques including retrograde approach, have raised hopes for improving the overall success. Reverse controlled antegrade and retrograde subintimal tracking is the most commonly used out of various retrograde approaches. In this review, the author has thrown light on a step-by-step approach of this technique, its standardization, various modifications along with complications.

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.