retrograde approach for revascularization of coronary chronic total occlusion

Vol. 60 - No. 5 MINERVA CARDIOANGIOLOGICA 461

grade. The intercoronary channel may be a septal collateral, an epicardial collateral or a bypass graft.

The first report of retrograde approach for CTO was published in 1990 by Kanh and colleagues, who described a retrograde wire crossing technique through a degen-erated saphenous vein graft.1 So far differ-ent retrograde techniques were introduced such as kissing wire technique, knuckle wire technique, the controlled anterograde and retrograde subintimal tracking (CART) technique, the reverse CART technique, and the modified reverse CART technique.2

Although in principle, a retrograde CTO crossing could be easier than an antegrade crossing in many CTO lesions,3 a proportion of CTOs remain very difficult to cross even with the retrograde approach. The length of the lesion, the duration of occlusion and the presence of calcium determines the dif-ficulty in crossing the CTO, even with the retrograde approach and among these the distribution of calcification is one of the most important issues. The presence of

Retrograde approach via collateral channels in coronary angioplasty for chronic total oc-clusion (CTO) can improve recanalization suc-cess rate. Most interventionalists will meet few cases where the retrograde approach will provide unequaled advantages, but many are held back from taking retrograde approach by lack of proper equipment and expertise. In this article, we give detailed description of all techniques to traverse the collateral chan-nels, and to cross the CTO by retrograde ap-proach. We also illustrate the difficulties in collateral channel crossing with different ex-amples providing a basic guide for case selec-tion purposes. Key words: Angioplasty, balloon, coronary - Cor-onary occlusion - Surgical procedures, mini-mally invasive

Retrograde approach via collateral chan-nels in coronary angioplasty for chronic

total occlusion (CTO) can improve the reca-nalization success rate. Most interventional-ists will meet a few cases where the ret-rograde approach will provide unequaled advantages, but many are held back from taking retrograde approach by lack of prop-er equipment and expertise. The retrograde approach requires a intercoronary channel between the occluded artery and another patent coronary artery, which enables the distal CTO site to be reached with retro-

Cardiovascular Interventional UnitDepartment of Internal Medicine and

Systemic Disease Catheterization Laboratory Cannizzaro Hospital

University of Catania, Catania, Italy

MINERVA CARDIOANGIOL 2012;60:461-72

S. D. TOMASELLO, F. MARZÀ, S. GIUBILATO, A. R. GALASSI

Retrograde approach for revascularization of coronary chronic total occlusion

Corresponding author: Prof. A. R. Galassi, FACC, FESC, FSCAI, Via Antonello da Messina 75, Acicastello, 95021 Ca-tania, Italy. E-mail: [email protected]

Anno: 2012Mese: OctoberVolume: 60No: 5Rivista: MINERVA CARDIOANGIOLOGICACod Rivista: MINERVA CARDIOANGIOL

Lavoro: 3311-MCAtitolo breve: Retrograde approach for revascularization of coronary chronic total occlusionprimo autore: TOMASELLOpagine: 461-72

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462 MINERVA CARDIOANGIOLOGICA October 2012

TOMASELLO RETROGRADE APPROACh FOR REVASCULARIZATION OF CORONARy ChRONIC TOTAL OCCLUSION

tegrade wiring too difficult or in case of a new re-attempt after previous antegrade failure.

Several angiographic factors can contrib-ute to retrograde success, such as the shape and the characteristics of the distal cap, the presence of well developed collaterals, the presence of non tortuous epicardial collat-erals and a healthy donor vessel. Of course, the operator who perform these kind of procedures need to have knowledge of dedicated materials and techniques besides an adequate skilfulness and experience. On the other hand unfavourable angiographic factors consist of not having clear collateral visualisation, cork-screw and angulated col-laterals, a calcified donor vessel, the pres-ence of multivessel disease and prior stent-ing in the donor vessel or presence of a bifurcation lesion at CTO distal cup (CTO exit).

Notably , the presence of left main cor-onary artery disease should be assessed accurately, even if a mild disease is dis-covered, the retrograde approach should be contraindicated. Continuous back and forth movements with the guiding catheter in the ostium of the left main artery might adversely and irreversibly affect it, creating more complications.

The operator should take in mind that the tracking of collateral circulation might lead ischemia for the patients with the conse-quence of chest discomfort during the pro-cedure, especially when the branch selected for retrograde approach supply almost the entire collateral circulation for the occluded vessel. At this regard it is very important to provide a strong anti-angina medical thera-py before the intervention.

Use of collaterals for retrograde approach

To provide an estimate size, coronary collaterals were measured by Werner et al with an electronic calliper on enlarged still images: CC1 collaterals were ≤0.3 mm in diameter and CC2 were ≥0.4 mm. When a retrograde channel is going to be used as

calcium on fluoroscopy usually indicates a long and difficult procedure. This means that MSCT coronary angiography could be very helpful to understand the course of the vessel when coronary vessel reconstruction is performed, similar to the angiographic views. however, the operator should not feel discouraged in the presence of some long and difficult looking lesions. If a good retrograde collateral channel is available, retrograde approach might be often surpris-ingly easy. On the other hand we should be aware that the retrograde approach is not a curiosity or a trick to show operative skills in live demonstrations. Although the tech-nique is conceptually simple, its intricate and demanding requirements discourage its application without adequate proctorship.4 Furthermore, the steep learning curve arises not only from the unaccustomed route used to approach the occlusion but also from the specific procedural material requirements and techniques.

Indication for retrograde approach

The proximal and distal cup characteris-tics are the main reason why the retrograde approach has been developed and gained successful application in percutaneous CTO recanalization. Indeed, the proximal fibrous cap is thicker and harder than the distal cap. Furthermore, the distal fibrous cap is typi-cally tapered, therefore when the operator views it from the proximal side it looks like a convex shape. This feature, especially if calcium and fibrous tissue are present at the location, put wires in trouble when they are pushed antegradely, as they are redirected into the subintimal space.

As recommended by many expert op-erators,5 an antegrade approach could be generally tried as first strategy. If antegrade dissection expands to the distal true lumen or if wire perforation occurs, a retrograde approach as a secondary approach should be performed.

Conversely, it advisable to perform the retrograde approach as primary strategy when some anatomical findings make an-

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RETROGRADE APPROACh FOR REVASCULARIZATION OF CORONARy ChRONIC TOTAL OCCLUSION TOMASELLO

also in very thin collateral branches. Gen-erally, septal collateral channel crossing is easier across LAD rather than RCA, because LAD septals origin is generally free of tortu-ousity and with smaller angle take off, com-pared to RCA septal collaterals.

Epicardial collateral channels are more difficult to negotiate and are prone to rup-ture when dilated. Also tortuous epicardial collaterals can lead to “accordion effect”, with occlusion and subsequent ischemia even when using new dedicated wires such as the Fielder FC and XT (Asahi Intecc, Ja-pan). These wires that are designed for col-lateral engagement are softer at the tip and with more support in the distal part of the body, compared to standard Fielder wires. Therefore, epicardial collaterals with a rea-sonable size and with minimal tortuousity are generally recommended for this ap-proach.9 Recently the introduction with the Sion guidewire from Asahi, an soft spring guidewire with a “dual core to tip” de-sign able to enhance durability and torque transmission, it is easy and safe to navigate tortuous epicardial channel. Moreover, the placement of a microcatheter and especially the Corsair from Asahi, within the collateral channel may favour its stretching, allowing a guide wire to advance easily.

It should keep in mind that an intramy-ocardial channel ruptures or punctures generally do not lead any major complica-tions,7, 8 whereas a rupture of an epicardial collateral channel might cause cardiac tam-ponade.

Finally, it is always better to choose the shortest collateral channel pathway because this improves support and the possibility to succeed in crossing the CTO.

Different strategies of retrograde approach

System setup

Generally two 7 Fr standard guiding cath-eters are placed into both coronary ostia. It is recommended to use both guiding cath-eters with side holes. Especially in case of

a preferential pathway for PCI, it is gener-ally viewed throughout its grade CC1 and CC2 course. Furthermore CC1 and CC2 are commonly found in CTOs. Werner et al. has reported them in approximately 85% of the cases.6

With the improved recent angiographer resolution this percentage is going to in-crease even further. however, in the re-maining cases when the collateral course is not clearly detected (CC0), a retrograde approach can still be attempted. The tortu-ousity of the collateral channel is one of the biggest contributors to difficulty and proce-dure risk, as well as presence of calcifica-tions into the donor vessel. Septal collateral channels tend to be less tortuous than cir-cumflex, right coronary artery or epicardial collaterals. however, it is also important to take multiple orthogonal views of the col-lateral channels before starting a retrograde procedure, as some straight looking col-laterals can be Z shaped in another view. Septal channel crossing is reasonably safe, and there are different methodology to en-gage them: 1) in case of a big septal branch (CC2) the operator might follow the path of the collateral vessel also using the selective coronary injection; 2) when there are mul-tiple septal connection of small diameter (CC1) the operator might try to push gently the wire looking for the best pathway in order to perform the so call “try and error” or “septal surfing” technique.7 however, in both cases if it is impossible to advance the guidewire a super selective dye injec-tion from a microcatheter might be able to identify a suitable collateral channel for ret-rograde recanalization which is hardly seen with a standard bilateral contrast injection.

In case in which a stent is present at the level of septal collateral origin sometimes a balloon dilatation of the septal branch across the stent struts it is needed in or-der to facilitate the advancement of the mi-crocatheter. Low pressure dilatation of the entire septal collateral might be performed in case of very small diameter branches,8 however the Corsair (Asahi Intecc, Japan), a microcatheter specifically developed for the retrograde approach, is able to be advanced

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lot of branching in the septal collaterals, but not enough to see the distal channels.

Differently, a “selective injection” is per-formed by pushing the microcatheter down the collateral channel and pulling out the wire. A 2 ml Luer Locker syringe filled with 1 ml of contrast is connected to the end of the microcatheter and sustained negative pressure is applied until blood flushes back into syringe. This takes some minutes as the collateral channels are small and blood flow is slow. Then the contrast is injected into the support microcatheter and a selec-tive channel angiogram is undertaken. The advantage of this technique is that the in-visible channels often open up with selec-tive injection, showing the operator a way to cross the collateral channels. however, with selective injections we cannot see the wire tip and its relationship with the anat-omy. When the wire is placed into the mi-crocatheter, the wiring continues under the guidance of our roadmap from the previ-ous injection. Selective injections are gener-ally used when the wire passes more than half way through the collateral channel and non selective injection cannot elucidate the path, or if it seems likely that the septal will rupture. Nevertheless, selective injection in the collateral channel might also carry, al-beit small, a possible risk of septal chan-nel dissection which increases if the small channel has a tortuous bend.

After the Fielder wire crosses the collat-eral channel, and reaches the distal CTO le-sion target artery, an attempt could be made to pass the microcatheter if the collaterals seem large enough. If there is no success, the microcatheter is exchanged with a 0.85- or 1.0- or 1.25-mm OTW balloon for sep-tal channel dilatation and inflated at low pressure (max 2-4 atm). Subsequently, gen-tle pressure is put into the system so that during heart contraction the balloon might slowly advance allowing several dilatations at different channel sites, then eventually permitting the balloon to pass. Alternative-ly, if both the microcatheter and the bal-loon do not cross the use of the septal dila-tor catheter (Corsair) might be employed. This is a microcatheter, which is dedicated

long collateral channel tracking it is recom-mended to use short guiding catheter (90 cm). however it is also possible shortening the a normal length guiding catheter until 85- and 90-cm in length.

Crossing the collateral channel

Generally a microcatheter is inserted into the target collateral artery with the aid of a Runthrough NS floppy wire (Terumo, Ja-pan). Regarding the use of the microcatheter, it is better to choose one that is softer than the others but not one prone to kinking, just in case the retrograde artery is consid-erably tortuous. Usually, the Runthrough is exchanged with a plastic-jacket hydrophilic guide wire (Fielder, Fielder FC, Fielder Ex-treme, Asahi Intecc, Japan, or Whysper LS or MS, Abbott, USA) as soon as the wire reaches the collateral branch. In some cases the Runthrough wire could reach the dis-tal target artery to the CTO lesion. In other hands, a plastic-jacket hydrophilic guide wire could be used from the start. The hy-drophilic guide wire has about a 45° bend at the tip. It is not often easy to select the best collateral channel to engage. Generally it is almost always better to choose the shorter of the two collaterals as this improves the support. Nevertheless the angle take off be-tween the origin of the collateral channel and the main branch vessel is an impor-tant issue, which might increasingly affect the procedure result. Indeed, a 90° angle take off does not often provide sufficient support to allow the guide wire to progress easily into the collateral channel. Gener-ally if no collateral engagement is obtained within several minutes of trying, a small volume of contrast dye following nitrates is injected through the guiding catheter, after redrawing the microcatheter from the main vessel, to visualize the collateral connec-tion. This so-called “non selective injection” has the advantage of allowing the operator to visualize the position of the wire tip in relation to the collateral channel anatomy. This technique may be very useful in deal-ing with the most proximal part of the col-lateral channel particularly when there is a

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Certainly, after recanalization the antegrade wire is passed through the occlusion, per-forming the standard PCI procedure (Figure 1). Using the Corsair, a soft hydrophilic wire might also be left in place and forced into the occlusion. This devices greatest advan-tage is that it reinforces guide wire torque transmission and it creates better backup support penetrating the complex lesions retrogradely. Alternatively, when using a standard microcatheter or an OTW balloon, thus it is not possible to force retrograde soft polymeric guidewire, it is possible ex-changed the wire with a stiffer spring one.

Long access and occasional loop route of the retrograde wire via an intercoronary channel, might determine a poor manoeu-vrability. In such conditions the use of a drilling strategy are generally preferred rather than a penetration strategy, more cumbersome to employ when manoeu-vrability is impaired. Therefore a “step-up approach” is generally suggested with the use of the Miracle series guidewires (Asa-

for collateral channels. It has a tapered tip and screw head structure, which reinforc-es torque transmission and creates better back-up support in penetrating the CTO.

The use of the channel dilator catheter might contribute in reducing the contrast load and radiation exposure, providing higher procedural success. Indeed, the use of this catheter might be employed from the beginning of procedure reducing the need from us of standard microcatheters. After crossing the collateral channel with either a standard microcatheter, balloon, or the channel dilator catheter is delivered into the distal coronary artery, the soft wire can be exchanged for a stiffer one, which may be used to cross the occlusion in a retrograde fashion.

The “Pure retrograde technique”

This recanalization technique uses a ret-rograde approach with a single wire, with-out a simultaneous antegrade approach.

Figure 1.—A, B) Left circumflex (LCX) CTO (dotted line) with collateral circulation from native right coronary artery (RCA) (arrowheads); C) the lesion was approached by retrograde through a collateral branch with a floppy hy-drophilic guidewire (Runthrough, Terumo, Japan) inserted in an Finecross microcatheter (Terumo, Japan), which was exchanged with a stiffer one able to advance up to the LCX ostium; D) the retrograde guidewire crossed the proximal cap of the occlusion and it was advanced into the antegrade guiding catheter; E) the retrograde microcatheter was exchanged with a low profile balloon (arrow) which was advanced through the vessel performing multiple dilatations by retrograde; F) afterwards an antegrade floppy guidewire was advanced, the retrograde wire was withdrawn and multiple dilatations were started; G) drug eluting stent (DES) implantation was then started; h) final result after DES implantation.

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Corsair is pulled back from the retrograde system contemporary. This is also the rea-son why retrograde wires for externaliza-tion should never be hydrophilic as these family of wires might carry the risk of cut-ting the intima of the coronary artery, and this is also the reason why the Rotawire (Boston Scientific, USA) provides generally a safer approach and could represent a rea-sonable alternative.

Although, the goal is to achieve the ad-vancement of retrograde wire in to the antegrade guiding catheter, two alterna-tives may be employed if it is impossible to achieve this result: firstly, the guide wire may be pushed all the way up the aortic arch. The curve of the arch acts as a bend and provides friction to track the wire. This is usually capable with soft wires but if a stiff wire has been used, careful attention should be paid on its tip, as it may dam-age the aorta endothelial; secondly, captur-ing the retrograde wire may be done using the loop snare guide wires retrieval systems with the “Retrograde wire Insertion in Ante-grade Device (RIAD)” technique. Indeed, if the guide wire catheter trapping technique is not employed, the retrograde guide wire may lack necessary support for the balloon catheter to advance.

On the contrary, a different method to generate the strongest backup support for the balloon catheter retrograde passage is the “reverse anchoring balloon technique”, which consist in the inflation of a antegrade balloon proximal to the CTO lesion anchor-ing the retrograde guide wire and gener-ating enough support for the retrograde balloon to advance.11 In order to perform this technique, the occlusion site should be located at the mid to distal part of the ves-sel. Finally, a small OTW balloon 0.85-1.0-1.25 mm with a 150-155 cm long shaft is generally employed to dilate the occlusion retrogradely. As mentioned at the beginning of this section, after obtaining retrograde recanalization, a soft-medium hydrophilic wire is passed anterogradely through the occlusion then a standard PCI procedure is performed.

hi Intecc, Japan), starting with a Miracle 3, then moving to a Miracle 4.5, 6 or 12 if the distal cap is too hard to cross.10 If the op-erator needs to redirect the retrograde wire away from the side branch of a bifurcation at the CTO distal they could exchange it for a Confianza wire (Asahi Intecc, Japan). Fi-nally this technique is preferred in an ostial CTO situation, or retrograde venous bypass graft reopening, due to the lack of ante-grade engagement.

After crossing the occlusion the distal end of the guidewire may be advanced in the antegrade guiding catheter by some cum-bersome maneuvers and trapped by a bal-loon anterogradely advanced in the guiding catheter, performing the “guidewire cath-eter trapping”. To employ this technique the antegrade balloon insertion may be performed without the use of a guide wire, and then inflates within the guiding cath-eter, before the side holes.

Generally after guidewire catheter trap-ping is it possible to advance the Corsair through the occlusion than a retrograde wire externalization should be performed. Employing this technique a 300 cm length not hydrophilic guidewire (such as BMW universal, Abbott, USA), is generally used to cross the CTO from the donor vessel guid-ing catheter all the way up to the opposite femoral access and externalizing the wire. To help the operator the Asahi Intecc devel-oped the RG3 wire, a 330 cm length, 0.010 inches guidewire with the first 170 cm hy-drophilic coated and the last 160 cm with a not hydrophilic silicon coat specifically de-signed to perform retrograde wire external-ization. With this guidewire it is very easy and fast the employment of this maneuver. After the retrograde wire externalization the lesion might be approach as a standard PCI, thus a small rapid exchange balloon (0.85-1.0-1.25 mm with a 150-155 cm long shaft) is slided onto the wire and advanced up an-terogradely to the tip of retrograde Corsair.

It should be taken in mind that in order to reduce the risk of coronary injuries when the removal of retrograde wire is it perform it is advisable to advanced antegradely a balloon or an OTW device while retrograde

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to reduce the use of contrast dye. After the antegrade wire crosses, the balloon catheter is advanced into the occlusion and dilata-tion is performed in the standard way.

The controlled antegrade and retrograde subintimal tracking technique

As already mentioned, this technique combines the simultaneous use of the an-tegrade with the retrograde approach. The basic idea about the controlled antegrade and retrograde subintimal tracking tech-nique (CART) technique is to create a subin-timal dissection with limited extension, only at the CTO site (Figure 3).14-16

First a wire is advanced antegradely, then it usually reaches the subintimal space at the CTO proximal cap or within a few mil-limetres of the occlusion. Secondly, anoth-er wire is advanced through the collateral channel and after being exchanged with a stiffer wire it is placed into the subinti-

The “Kissing retrograde technique”

This technique combines the antegrade and retrograde approaches simultaneously. If the CTO lesion is relatively soft, the retro-grade wire could advance easily, stopping it half way. If the tip comes near the CTO proximal, it is aimed at the antegrade guide wire, finally both the antegrade and retro-grade guide wires. Sometimes, unexpect-edly, if the antegrade and retrograde wires are in different layers, it is difficult to align them due to same reason in the antegrade approach (Figure 2).

The “Landmark retrograde technique” is a type of ‘kissing wire’ because the retro-grade wire is used as a landmark for the antegrade guide wire which is the only wire to advance.12, 13 Instead, the actual kissing wire technique advances both of the guide wires into the occlusion with each one try-ing to meet the opposite wire. The land-mark retrograde technique is generally used

Figure 2.—A) Left anterior descending (LAD) proximal occlusion with ipsi-lateral circulation; B) the lesion was ap-proached by antegrade using a soft hydrophilic guidewire (Fielder, Asahi Intecc, Japan) which was not able to get through the of occlusion; C) contralateral contrast mean injection from microcatheter was performed to visualize the retrograde collateral circulation (dotted line); D) a retrograde hydrophilic guidewire (Runthrough, Terumo, Japan) inserted in a Finecross microcatheter (Terumo, Japan) was advanced up to the distal cap of the occlusion; E) the retrograde wire was used as a landmark for the advancement of the antegrade wire. Subsequently, an intermediate-stiffness guidewire (Medium) with a microcatheter was inserted in order to perform the kissing wire technique; F) Medium guidewire was able to cross the occlusion by antegrade; G) Medium guidewire was exchanged with a floppy guidewire (Prowater flex, Asahi Intecc, Japan) and subsequently multiple dilatations with balloons were executed; h) final result after drug eluting stent implantation.

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keep this subintimal space open, is to leave the deflated balloon in place. This makes it easier to advance the antegrade wire fur-ther along the deflated retrograde balloon, which lies from the subintimal space to the distal true lumen CTO (Figure 4). This tech-

mal space at the CTO site. After advancing a small balloon (1.0-1.25-1.5 mm) over the retrograde wire in subintima, the balloon should be inflated in subintima and also on the course from this subintimal space to the CTO distal end. A good suggestion to

Figure 3.—A cartoon scheme of the CART technique. A) A wire is advanced antegradely reaching the sub-intimal space at the CTO proximal cap; B) another wire is advanced through the collateral channel and after being exchanged with a stiffer wire it is placed into the sub-intimal space at the CTO site; C) a small sized balloons up to 2.0 mm in diameter over the retrograde wire in sub-intima is inflated near to the CTO distal end; D) the deflated balloon is left in place to keep the sub-intimal space open; E) subsequently, the antegrade guidewire is advanced along to the deflated retrograde balloon; F) dilatation and stent implantation is performed with the stent positioned partly across the dissected CTO plane. (From Galassi et al. Percutaneous coronary intervention of chronic total occlusion- Alpha libri 2010).

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cases this retrograde wire may succeed in crossing the lesion, opening up the occlu-sion and successfully recanalising the artery without the need of any other antegrade work. however, an antegrade stiff wire is generally required in order to get through the dissected lumen created by the knuckle wire. Some work should be performed to re-enter the true lumen. After crossing the antegrade wire, a balloon catheter is ad-vanced into the occlusion and is dilated the standard way.

The reverse CART technique

A reverse approach of the standard CART consists of dilating the balloon that is in the subintimal space, within the CTO lesion an-tegradely, instead of retrogradely, in order to make the target space for the retrograde guide wire penetration (Figure 5).7, 8 Never-theless, guide wire manipulation is more dif-

nique allows limited subintimal tracking sit-uated only in the portion of the CTO lesion, and avoids problems when re-entering into the distal true lumen. After successful reca-nalization, dilatation and stent implantation are performed with the stent positioned partly across the dissected CTO plane.

The “Knuckle technique”

This is a variation of the CART technique, where a dissection of the subintimal space is created by forming a loop in the retro-grade wire which is then advanced to the occluded segment. The principle is the same as the STAR technique from the an-tegrade approach with the positive lack of flow to propagate the dissection distally.17 For this technique soft hydrophilic wires are preferable especially if there is good back support from the retrograde micro-catheter, like with channel dilator. In few

Figure 4.—A) right coronary artery (RCA) ostium CTO with collateral circulation from septal branches; B) approach of the lesion by retrograde through a septal branch with a floppy hydrophilic guidewire (Runthrough, Terumo, Japan) inserted in an Echelon microcatheter (EV3 Vascular, USA); C) microcatheter did not advance through the collateral branch, thus it was exchanged with an OTW low-profile balloon which was advanced up to the distal cap of the oc-clusion; D) Runthrough was exchanged with a stiff non-hydrophilic guidewire (Miracle 4.5, Asahi Intecc, Japan) which was able to cross the occlusion. however the guidewire could not be advanced into the RCA guiding catheter because it was in a different plane. Therefore a stiff guidewire (Conquest Pro 9, Asahi Intecc, Japan) was inserted by antegrade with a microcatheter to perform the kissing wire technique; E) the antegrade stiff guidewire was not able to penetrate the true lumen, thus the retrograde balloon was inflated in order to perform the CART technique; F) the antegrade guidewire was able to get through the occlusion; G) the stiff antegrade wire was subsequently exchanged with a floppy guidewire and multiple dilatations with different balloons were started; h) final result after DES implantation.

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nels engagement, it has made this approach the most diffuse way to perform a retrograde recanalization in case in which it is not pos-sible to achive the success with the pure ret-rograde technique. Indeed, Corsair reinforces torque guide wire transmission, creating bet-ter back-up support to penetrate the CTO,

ficult through the retrograde than the ante-grade approach because of the long course and there are many angulations over the en-tire course of the retrograde path. This is why this technique was hardly ever performed in the past. As the channel dilator catheter Cor-sair is dedicated in selective collateral chan-

Figure 5.—A cartoon scheme of the reverse CART technique. A) a wire is advanced retrogradely through the collateral channel, reaching the subintimal space at the CTO distal cap; B) another wire is advanced antegradely and it is placed into the subintimal space at the CTO site; C) a small sized balloons up to 2.0 mm in diameter over the retrograde wire in sub-intima is inflated near to the proximal CTO site; D) A good suggestion to keep this subintimal space open, is to leave the deflated balloon in place; E) subsequently, the retrograde guidewire is advanced along to the deflated ante-grade balloon; F) dilatation and stent implantation are performed with the stent positioned partly across the dissected CTO plane. (From Galassi et al. Percutaneous coronary intervention of chronic total occlusion- Alpha libri 2010).16

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procedure di rivascolarizzazione coronarica delle occlusioni croniche totali. Sebbene siano rari i casi in cui tale tecnica fornisce vantaggi ineguagliabili rispetto all’approccio classico anterogrado, è pur vero che spesso molti cardiologi interventisti sono riluttanti all’impiego di tale strategia di rivascolariz-zazione, soprattutto per la mancanza di un’adegua-ta competenza tecnica. In questo articolo, verran-no descritte in maniera dettagliata tutte le strategie mediante le quali è possibile ottenere la rivascola-rizzazione percutanea di un occlusione cronica per via retrograda attraverso i rami collaterali. Inoltre, utilizzando diversi esempi, illustreremo le difficoltà tipiche della tecnica ed alcuni accorgimenti proce-durali, al fine di fornire le basi per la selezione dei casi che meglio si prestano a tale tipo di procedura di rivascolarizzazione coronarica.

Parole chiave: Angioplastica coronarica, palloncino - Occlusione coronarica - Trattamento chirurgico minin-vasivo.

References

1. Kahn JK, hartzler GO. Retrograde coronary angi-oplasty of isolated arterial segments through saphe-nous vein bypass grafts. Cathet Cardiovasc Diagn 1990;20:88-93.

2. Galassi AR, Tomasello SD, Costanzo L, Tamburino C. Retrograde approach for chronic total occlu-sion percutaneous revascularization. Interv Cardiol 2010;3:391-403.

3. Fuji K, Ochiai M, Mintz GS, Kan y, Awano K, Masu-tani M et al. Procedural implications of intravascular of ultrasound morphologic features of chronic total occlusions. Am J Cardiol 2006;97:1455-62.

4. Di Mario C, Barlis P, Tanigawa J, Locca D, Bucciarel-li-Ducci C, Kaplan S et al. Retrograde approach to coronary chronic total occlusions:preliminary single European centre experience. EuroInterv 2007;3:181-7.

5. Joyal D, Thompson CA, Grantham JA, Buller CE, Rinfret S. The retrograde technique for recanalization of chronic total occlusions:a step-by-step approach. JACC Cardiovasc Interv 2012;5:1-11.

6. Werner GS, Ferrari M, heinke S, Kuethe F, Surber R, Richartz BM et al. Angiographic assessment of collat-eral connection in comparison with invasively deter-mined collateral function in chronic coronary occlu-sion. Circulation 2003;107:1972-7.

7. Sianos G, Karlas A. Tools & techniques: CTO--the ret-rograde approach. EuroIntervention 2011;7:285-7.

8. Ochiai M. Retrograde approach for chronic total occlusions:present status and prospects. EuroInterv 2007;3:169-73.

9. Wu EB, Chan WWM, Man yu C. Retrograde chronic total occlusion intervention:Tips and tricks. Catheter Cardiovasc Interv 2008;72:806-14.

10. Galassi AR, Tomasello SD, Costanzo L, Tamburino C. Anterograde techniques for percutaneous revascu-larization of chronic total coronary occlusions. Interv Cardiol 2010;3:377-90.

11. Saito S. Different strategies of retrograde approach in coronary angioplasty for chronic total occlusion. Catheter Cardiovasc Interv 2008;71:8-19.

therefore favouring retrograde true lumen penetration. however, if retrograde subin-timal dissection occurs, the retrograde wire may still find its way out of the true lumen vessel if a balloon is inflated in the subintima antegradely. In that case it is advisable to use big balloon (3.0-3.5 mm in diameter).

If a large dissection is created, the pen-etration of retrograde wire might be very cumbersome. In such cases the IVUS reen-try guided technique might be used. This consist in the advancement of a IVUS probe (a Volcano ultrasound system is generally preferred) within the antegrade system try-ing to recognized the tip of retrograde in the dissection plane, redirecting it through the proximal true lumen. That elegant ap-proach was developed by Japanese opera-tors and in expert hands it is able to obtain a very high rate of procedural success.18

The main advantage of the reverse CART is that the channel dilator easily tracks the retrogradely way without the disadvantages and difficulties to advance a balloon cath-eter retrogradely. On the other hand the balloon catheter can easily find the dissec-tion way from antegrade approach. A plas-tic wire is generally used to cross the con-nection between the distal true lumen and the antegrade dissection, however in same cases a spring stiff guidewire can be useful.

Conclusions

In case of suitable collateral circulation retrograde approach might improve pro-cedural success rate, especially in case of difficult anterograde approach. Although the retrograde approach is conceptually simple, it requires very skill operators and a long learning curve, which intricate and demanding supplies discourage without ad-equate proctorship.

Riassunto

Approccio per via retrograda per rivascolarizzazio-ne coronarica delle occlusioni croniche totali

L’approccio per via retrograda attraverso i rami collaterali può migliorare il tasso di successo delle

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reverse-anchoring techniques three years after failed PCI via a retrograde approach. Cathetet Cardiovasc Interv 2008;71:810-4.

16. Galassi et al. Percutaneous coronary intervention of chronic total occlusion. Alpha libri 2010.

17. Colombo A, Mikwall GW, Michev I, Iakovou I, Ai-roldi F, Chieffo A et al. Treating chronic total oc-Treating chronic total oc-clusions using suboptimal tracking and reentry:the STAR technique. Catheter Cardiovasc Interv 2005;64:407-11.

18. Kimura M, Katoh O, Tsuchikane E, Nasu K, Kino-shita y, Ehara M et al. The effi cacy of a bilateral ap-The efficacy of a bilateral ap-proach for treating lesions with chronic total occlu-sions the CART (controlled antegrade and retrograde subintimal tracking) registry. JACC Cardiovasc Interv. 2009;11:1135-41.

12. Lin Th, Wu DK, Su hM, Chu CS, Voon WC, Lai WT et al. Septum hematoma:a complication of retro-grade wiring in chronic total occlusion. In J Cardiol 2006;113:e64-e66.

13. Niccoli G, Ochiai M, Mazari AA. A complex case of right coronary artery chronic total occlusion treated by a successful multistep Japanese approach. J Inva-J Inva-sive Cardiol 2006;18:E230-E233.

14. Surmely JF, Tsuchikane E, Katoh O, Nishida y, Naka-yama M, Nakamura S et al. New concepts for CTO recanalisation using controlled antegrade and retro-grade subintimal tracking the CART technique. J In-vasive Cardiol 2006;18:339-40.

15. Matsumi J, Saito S. Progress in the retrograde ap-proach for chronic total coronary artery occlusion: a case with successful angioplasty using the CART and

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retrograde approach for revascularization of coronary chronic total occlusion

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