Case 250: Manual of CTO PCI - Retrograde via ipsilateral epicardial collateral: tip in to the rescue

A patient with medically refractory angina was referred for PCI of an LAD CTO. The CTO had a blunt and calcified proximal cap, length of about 15-30 mm, diffusely diseased and calcified distal vessel that was filling via an ipsilateral epicardial collateral. Antegrade wiring attempts with a Gaia Next 2 and 3 and a Hornet 14 resulted in extraplaque wire advancement. The epicardial collateral was successfully crossed with a Suoh 03 wire but the Caravel microcatheter could not reach the CTO (a 100 cm long guide was used). A Gladius Mongo wire was advanced into the antegrade guide catheter where it was “tipped in” an antegrade Corsair XS microcatheter. The Corsair XS was advanced across the CTO followed by insertion of an antegrade wire, intravascular lithotripsy and stenting with a nice final result.

[@abdelrahmangamal8271]

Excellent Ahmed and Manos the q is what if tip in failed and thank u for sharing this amazing case

[@shangz0216]

Thanks for the excellent case presentation.

[@Stentordoc]

Amazing case !

[@avaisjabbar3324]

Thank you sir, had your retro wire ended in subintimal space, doing a reverse cart in a single guide would have been difficult. Would you have used ping pong guides? Any solutions for doing a reverse cart in a single guide?

[@user-yq3yg7bq1g]

Why not attempt ADR once you were extra plaque prior to going retrograde ? Even though there is disease, there are no sig branches and may have been worth an attempt

[@manosbrilakis]

Good point - reentry would likely have been quite challenging here given small size of the distal vessel and the presence of calcification.