An algorithmic approach for the management of ostial right coronary artery chronic total occlusions

Abstract

Treatment of ostial chronic total occlusions (CTOs) of the right coronary artery (RCA) can be challenging. We present an algorithmic approach to the management of such lesions that incorporates all contemporary equipment and techniques. If the RCA ostium can be engaged with a guide catheter then antegrade crossing attempts should be performed. If the antegrade guidewire enters the subintimal space, re-entry into the distal true lumen is performed provided that the antegrade guide catheter provides enough support. If re-entry cannot be achieved, the antegrade wire is left in place to facilitate retrograde recanalization attempts (usually performed using the reverse controlled antegrade and retrograde tracking and dissection-reverse CART-technique). If the RCA ostium cannot be engaged with a guide catheter (for example in flush ostial occlusions) or if the guide catheter does not provide sufficient support, a primary retrograde approach is required, aiming for retrograde guidewire puncture into the aorta, followed by snaring and externalization. Retrograde guidewire puncture can be challenging, requiring use of stiff, highly penetrating guidewires or occasionally use of the Carlino technique. The aforementioned algorithm can facilitate crossing of ostial RCA CTOs.

Stumpless ostial right coronary artery chronic total occlusion: Retrograde approach

“…1,2 The most common target vessel in CTO percutaneous coronary interventions (PCI) is the right coronary artery (RCA), which represents half of all CTO lesions in contemporary registries. 3 Ostial RCA lesions are a challenging subset due to a lack of antegrade access or guide catheter support and heavy calcification, which is commonly observed. Stumpless ostial RCA CTO requires retrograde expertise due to the unavailability of antegrade wiring.…”

Role of the retrograde Carlino technique for chronic total occlusion percutaneous coronary intervention

“…The Carlino technique 6,7 consists in the gentle injection of a small volume of contrast media through a microcatheter advanced into the occlusion, with the goal of either modifying plaque compliance (if the microcatheter is located intraplaque) or providing topographic information with regard to microcatheter position (in the main segment of the occluded vessel vs. a side branch) if the latter is in the extraplaque space. 8 While the Carlino technique is routinely utilized by hybrid operators, [9][10][11][12] the outcomes of such an approach have been characterized mainly in the setting of the antegrade approach. 13 The aim of this study is to characterize the practice patterns, applications, and outcomes of the Carlino technique during the retrograde approach for CTO PCI.…”

Ostial Chronic Total Occlusion Recanalization: Hostile as It Looks?

“…However, success rates were similar between ostial and nonostial CTOs (80.0% vs 81.9%, P ¼ 0.706). Avran et al 17 recently published an algorithm focused on the technical aspects of ostial right coronary artery CTO PCI, which can help streamlining the approach to this challenging lesion subset.…”