Retrograde recanalization of chronic total occlusion. A novel maneuver of the old technique

Percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) remains one of the most challenging procedures in interventional cardiology. In case of anterograde failure to cross the CTO lesion, the retrograde approach may improve the success rate of such procedures [1]. Factors predicting procedural success have been described before [2]. Thus, various devices and tips and tricks have been developed to further improve this strategy [3]. We present a novel wiring maneuver that enabled the operator to successfully complete the procedure.
A 52-year-old patient with a history of previous PCI of the right and the left circumflex coronary arteries, nicotine use, hypertension and dyslipidemia was admitted for a percutaneous attempt to open the CTO of the proximal left anterior descending coronary artery (LAD) (Figure 1 A). Single-photon emission computed tomography revealed 20% inducible ischemia of the anterior wall. The left femoral artery was punctured and the left coronary artery was cannulated with an EBU 7 Fr guide catheter (GC). The anterograde approach with standard workhorse guidewires was unsuccessful. Virtually no LAD stump was visualized; therefore no CTO-dedicated wires were used and a retrograde approach was attempted. Sion (Asahi Intecc, Japan) guidewire with a Finecross (Terumo, Japan) 130 cm microcatheter were advanced retrogradely up to the LAD occlusion via the epicardial LCx collateral. After unsuccessful attempts to cross the CTO with Fielder FC, XT (Asahi Intecc), and Miracle Bross 12 (Asahi Intecc) guidewires, it was finally opened with a 180 cm Confianza PRO 12 (Asahi Intecc) (Figure 1 B). The wire was then advanced retrogradely into the GC (up to the level of the aortic arch). Finecross microcatheter turned out to be too short to cross the occlusion and reach the GC retrogradely. Thus, an over-the wire (OTW) balloon was placed into the GC and inserted within it over the Confianza guidewire tip and further advanced anterogradely up to the CTO lesion (Figures 1 D, E). The Finecross microcatheter was then withdrawn and the retrograde wire was exchanged for an antegrade Fielder FC. The next steps of CTO PCI were straightforward. After predilatation two drug-eluting stents were implanted. A good angiographic result was achieved (Figure 1 F). The postprocedural course was uneventful.
Subsequently we performed a bench study of cannulation of an OTW balloon using a Confianza wire within the 7 F GC. This technique proved...


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