Case 221: Manual of CTO PCI - Reverse CART in the LIMA

A prior CABG patient was referred for PCI of an LAD CTO. All prior bypass grafts, including the LIMA-LAD were occluded. Two stent layers had been previously placed from the LAD into the diagonal branch making the proximal cap ambiguous. A primary retrograde approach was attempted but a retrograde wire could not puncture through the previously placed stents, even after doing intravascular lithotripsy from the LAD into the diagonal. Coronary CTA showed two stent layers and heavy calcification. A repeat retrograde attempt was performed advancing the retrograde guidewire into the LIMA stump. After doing both antegrade and retrograde Carlino a retrograde Sion black wire was advanced extraplaque into the LIMA, followed by successful crossing using reverse CART. After wire externalization, antegrade wiring of the LAD through a Sasuke, removal of the retrograde gear and stenting of the LIMA-LAD a nice final result was achieved.

[@user-eh7kj5th9h]

Congratulations! great case

[@user-el3rb1ny1n]

Absolutely fantastic

[@michalesiak7239]

Wow🤯 and the follow up❤

[@narendhiranpandurangan684]

Great case

[@shadiyounis8560]

Great strategy

[@shangz0216]

Thanks for the excellent case sharing.

[@muhammadsabry7720]

Great case strategy

[@rogeriomoura6557]

FANTASTIC

[@maisamtaherian986]

Incredible 👏👏🌹❤️

[@kalyanmuvvavenkateswarlu5482]

Thank you for showing the case, sir when a knuckle is formed is it subintimal or intimal(intraplaque)