1. Newer methods to Facilitate the Retrograde Approach
Barry D. Rutherford, MD
CRT 2012

2. Case 1: 63-Year-Old Female CTO of RCA Previously Failed Antegrade Attempt

3. ViperWire Advance™ 335 cm, retrograde into aortic root
2.0x20 Voyager balloon
ViperWire Advance™ 335 cm, retrograde into aortic root
Case 1

4. Case 1: 63-Year-Old Female CTO of RCA Previously Failed Antegrade Attempt

5. Case 1: “As Simple as A, B, C”
Corsair and Fielder FC to negotiate epicardial collaterals and achieve retrograde crossing of lesion
ViperWire retrograde to aortic root provides enough support to advance balloon on retrograde wire and dilate the lesion
Convert to simple antegrade wire crossing to deliver stents

6. Case 2: 71-Year-Old Female CTO of LAD Previously Failed Antegrade Attempt

7. FineCross™ Corsair Fielder XT
Case 2

8. 2.5x15 balloon on antegrade wire (Confianza Pro 12)
Reverse CART
2.5x15 balloon on antegrade wire (Confianza Pro 12)
Corsair
Case 2

9. Case 2: 71-Year-Old Female CTO of LAD Previously Failed Antegrade Attempt

10. Case 2 Corsair and Fielder FC to pass septal collaterals
Retrograde wires unable to cross lesion
FineCross, Confianza Pro 12, antegrade approach to deliver balloon for Reverse CART
Retrograde, Confianza Pro 12, Corsair, then advanced to the antegrade guide and exteriorization of Viper wire

11. Reverse CART Technique
D. Joyal et al. JACC Int 2012;5:1-11

12. Case 3: 61-Year-Old Male CTO of RCA Post CABG

13. Antegrade wire: Fielder XT Retrograde wire: Confianza Pro 12
Reverse CART
Antegrade wire: Fielder XT
Anchoring Balloon
Retrograde wire: Confianza Pro 12
Corsair
Case 3

14. Case 3: 61-Year-Old Male CTO of RCA Post CABG

15. Case 3: Corsair, Fielder FC to negotiate septals
Use of anchoring balloon to stabilize the antegrade guide
Reverse CART to deliver retrograde wire to antegrade guide
Exteriorization of Viper wire, then antegrade delivery of balloons and stents

16. Case 4: 67-Year-Old Female CTO at site of previous stent in RCA Post CABG

17. ViperWire Advance™ 335 cm, retrograde into aortic root
Corsair
ViperWire Advance™ 335 cm, retrograde into aortic root
Angiotech ENSnare® System in Antegrade Guide
Case 4

18. Case 4: 67-Year-Old Female CTO at site of previous stent in RCA Post CABG

19. Case 4: Corsair, Fielder FC to negotiate septals
Reverse CART to deliver retrograde wire to aortic root; retrograde wire could not be passed into antegrade guide
Use of Angiotech EN Snare to capture retrograde wire in the aortic root
Exteriorization of Viper wire, then antegrade delivery of balloons and stents

20. Knuckle Wire Technique
D. Joyal et al. JACC Int 2012;5:1-11

21. Case 5: THE LOMBARDI SPECIAL 69-Year-Old Male CTO of RCA Post CABG

22. Knuckle Wire Technique
CrossBoss
Pilot 200
Fielder XT
Corsair
Case 5

23. Case 5: THE LOMBARDI SPECIAL 69-Year-Old Male CTO of RCA Post CABG

24. Antegrade Knuckle Wire
2.5x20 Apex Balloon
Antegrade Knuckle Wire
Retrograde Wire
Case 5

25. Case 5: THE LOMBARDI SPECIAL 69-Year-Old Male CTO of RCA Post CABG

26. Case 5: “The LOMBARDI Special”
Corsair, Fielder FC to negotiate epicardial collateral: Tip injections from Corsair
Knuckle wire technique from antegrade CrossBoss and retrograde Corsair Knuckle wires: Fielder XT, Pilot 200, Confianza Pro 12
Deliberate subintimal injections, both antegrade (CrossBoss) and retrograde (Corsair) “Mauro Carlino Technique”
GuideLiner as conduit to exteriorize the Viper wire, then antegrade delivery of balloons and stents
Procedure time: 3 hours 30 minutes Fluoro time: 76.5 min mGy = 9797