1. A Step-by-Step Description of the Retrograde
Approach: Collateral Examination, Guidewire
and Microcatheter Selection
AR Galassi, MD, FACC, FESC, FSCAI
Head of Cardiac Catheterization and
Interventional Cardiology Unit,
Division of Cardiology, Ferrarotto Hospital
Associate Professor of Cardiology
University of Catania, ITALY

2. Alfredo R. Galassi, MD
I have no real or apparent conflicts of interest to report.

3. Why Retrograde Approach?
By Ochiai/Japan

4. Why Retrograde Approach?
By Ochiai/Japan

5. Indications of Retrograde Approach as a Primary Procedure
Antegrade wiring seems very difficult in terms of anatomical factors (complex CTO)
The patient has visible and continuous collaterals
The donor vessel is healthy
Re-attempt after previous failure

6. EuroInterv 2008; 4 : 84-92

7. Treatment Strategy
Sianos et al EuroInterv 2008

8. Success and Indications of Retrograde Approach Personal Experience 2007-2010

9. Standardized Procedures of Retrograde Approach
A 7 Fr guiding catheter with a side hole is inserted from left femoral or left brachial artery
• Super-selective dye injection from a microcatheter is performed to identify the “visible”collateral
Septal collaterals are preferred usually, because they are dilatable
• A slippery wire with a microcatheter is employed

10. Tip Microcatheter Injection
Non-selective channel injection
Selective channel injection 10

11. Collateral Connection Size
CC0 = no continuous connection
CC1 = (blue arrows) continuous
threadlike connecrtion
CC2 = (green arrows) continuous small side branch–like size collateral 11

12. Collateral Course and Their Appearance Depending on Different Multiple Orthogonal Views12

13. Characteristics of Specific Collateral Channels
By Katoh O/Japan 13

14. Classifications of Collateral Corkscrew-like Morphology
By Katoh O/Japan 14

15. What the Guidewire Looks Like When it is Introduced by Retrograde15

16. Collateral Channel at a 90° Angle Take-off16

17. Retrograde/CART Experiences 2008-2010
Center
Overall Success
Author
Journal/Venue
Toyohashi
133/157 (84.7%)
Rathore
Circ Intv 2009
JACC Intv 2010
Predictors of failure were primarily related to characteristics of the collateral channel.
There were no significant CTO morphologic or anatomic predictors of retrograde success or failure.

18. Standardized Procedures of Retrograde Approach
Slippery wires used for collaterals:
- Epicardial Runthrough (Terumo), Whisper (Abbott)
Sion (Asahi)
- Septal Fielder FC (Asahi), Fielder XT (Asahi)
- Cork screw Fielder XT, Fielder XT-R (Asahi)
After the successful delivery of a slippery wire, the microcatheter is advanced towards the distal coronary artery via collaterals
If the microcatheter cannot be advanced, septal dilatation may be performed with a mm OTW balloon to 2-3 atm

19. Wires for Retrograde Approach to Cross the Lesion
Soft wires may cross the lesion, especially by use of channel dilator, otherwise stiffer wires are generally necessary to cross the lesion
Runthrough, Fielder FC or XT or XT-R
Miracle 3.0 or 4.5 or 6.0
Confianza Pro 9.0 gr
Confianza Pro 12.0 gr 19

20. OTW Microcatheters for CTOs
Manufacturer
Microcatheter
Shaft lenght
Crossing Profile
Inner lumen size
Asahi
Stride
130, 150 cm
0.029”/0.73 mm/2.2 Fr
0.016”
Balt
Vasco+10
155 cm
0.025”/0.63 mm/1.9 Fr
0.0165”
Boston
Excelsior 1018
175 cm
0.026”/0.66 mm/2.0 Fr
0.019”
Tracker Excel 14
150 cm
0.025”/0.63 mm/1.9Fr
0.017”
Excelsior SL 10
0.022”/0.56 mm/1.7Fr
Cordis
Prowler 14
Prowler 10
0.015”
Rapid Transit
0.030”/0.76 mm/2.3Fr
EV3
Echelon 14
Echelon 10
0.022”/0.56 mm/1.7 Fr
Spectranectis
Quick Cross
135 cm
Terumo
Finecross
130, 150 cm
0.024”/0.60 mm/1.8 Fr
Progreat 2.4
110, 130 cm
0.031”/0.80 mm/2.4 Fr
0.021”
Progreat 2.0
Vascular solution
Skyway
138 cm

21. Advantage of the use of a microcatheter for collateral channel crossing21

22. Dedicated Microcatheters for CTO
Manufacturer
Microcatheter
Shaft lenght & diameter
Inner lumen size
Characteristics
Asahi
Tornus
135 cm 2.6 Fr
0.016”
Rotational burrowing microcatheter
135 cm 2.1 Fr
Corsair
cm 2.6 Fr
0.015”
Channel dilator catheter for retrograde approach
Vascular solution
Twin Pass
138 m 1.9 Fr
Double lumen microcatheter
Gopher
142 cm 3.0 Fr
0.017”
Rotational support microcatheter
St. Jude
Venture
145 m 2.2 Fr
0.019”
Flexible tip microcatheter manually manoeuvred

23. The Channel Dilator Catheter (Corsair)
For tip flexibility & vessel trackability
Provides superior tip flexibility which enables smooth approaches to narrow tortuous vessels, such as septal channels
ø 0.82mm (2.5Fr)
ø 0.86 mm (6)
ø 0.86mm (2.6Fr)
Marker coil
Polyurethane resin + Tungsten powder
Tungsten braiding
Courtesy of Dr Kato

24. Advantages of ASAHI Corsair
ASAHI Corsair vs Microcatheters
Microcatheter has a marker closer to the tip compared to OTW Balloon Catheter which makes it easy to identify the distal tip under fluoroscopy
Unlike other general microcatheters, ASAHI Corsair has soft tip with tungsten powder mixed, and on top of that, it has a 0.8 mm platinum marker coil situated at 5 mm from the tip
General Microcatheter
5mm
Soft tip with tungsten powder
0.8mm
Platinum marker coil
Marker
Courtesy of Dr Kato

25. Experience with Channel Dilator (Corsair): 90/93 Channel Crossing
Tsuchikane et al, JACC Intv 2010

26. Corsair: Extraordinary trackability
(O. Katoh)

27. Would You Believe that this Epicardial Channel can be Crossed Without Perforation?

28. I Was Sure That Was Impossible…..
O. Katoh

29. OTW Balloons < 1.5 mm Diam for CTOs Shaft lenght & diameter
Manufacturer
Balloon
Shaft lenght & diameter
Balloon size
(diameter x lenght)
Entry tip profile
crossing profile
Terumo
Riujin OTW
135, 148 cm Fr
mm X mm
0.0165”
0.023”
Boston
Apex
140 cm Fr
1.5 mm X mm
0.017”
Invatec
Falcon Piccolo
145 cm Fr
0.0168”
0.022”-0.023”
Falcon CTO
145, 160 cm
mm X mm
0.016”
0.021”
Abbott
Voyager
135 cm Fr
1.5 mm X mm
Medtronic
Sprinter
138 cm
1.5 mm X mm
CID Acrostak
Across CTO
150 cm Fr
mm X
0.015
Clearstream
Ezecto
140 cm
mm X 15 mm
0.022”
SIS Medical AG
NIC nano
160 cm
0.85 mm X mm
0.0195”
NIC 1.1 OTW
1.1 mm X mm
0.0205”

30. IVUS-Guided Reverse CART: 31 cases
Rathore et al, JACC Intv 2010; also Banerjee et al, JIC 2010

31. Retrograde Stepwise Approach in 2010
Retrograde wire crossing (Channel Dilator)
Kissing wire
Retrograde knuckle wire technique and antewire crossing
CART/ reverse CART

32. Thank You For Your Attention
Conclusions
Retrograde approach might be choosen as primary strategy, if:
1) The CTO has several unfavorable anatomical features
2) The CTO is relatively long ( ≥15~20mm)
3) The distal vessel receives visible collaterals
4) The donor vessel is healthy (or can be treated before)
5) The procedure is re-attempt after previous failure
• With the use of new guide wires, devices (Channel Dilator, Corsair) and techniques, the overall success of retrograde approach has increased significantly during the last years but still predictors of failure were primarily related to characteristics of the collateral channels
• The operator should learn to be versatile and be ready to adopt different techniques during the same procedure
Thank You For Your Attention