Faster, easier, safer: “guideliner reverse CART” for retrograde chronic total occlusion interventions

Abstract

The retrograde approach has revolutionized percutaneous coronary intervention (PCI) to coronary chronic total occlusions (CTO) by significantly improving success rates [1,2]. The retrograde approach involves two main steps: (a) delivering a guidewire and microcatheter distal to the occlusion via a collateral vessel and (b) crossing the CTO segment [2,3]. CTO crossing can be achieved using three techniques (Fig. 1a): (a) using the distal true lumen guidewire as a marker for antegrade guidewire crossing ("just marker" and "kissing wire" techniques); (b) achieving "true to true" lumen crossing with the retrograde guidewire; or (c) using dissection/re-entry techniques, in which the guidewire is redirected from the subintimal space into the true lumen. There are two main dissection/re-entry techniques: in controlled antegrade and retrograde subintimal tracking (CART), a balloon is inflated over the retrograde guidewire allowing the antegrade guidewire to enter the distal true lumen. In reverse CART a balloon is inflated over the antegrade guidewire followed by retrograde guidewire crossing into the proximal true lumen using the space created by the antegrade balloon inflation.With the advent of the channel dilator (Corsair, Asahi Intecc, Nagoya, Japan), reverse CART is currently the most commonly utilized retrograde CTO crossing technique, since it is very common for the antegrade and retrograde guidewires to enter the subintimal space during CTO segment crossing attempts, especially in long occluded segments. Reverse CART also allows for wire externalization, which provides the strongest support for balloon/stent delivery. However, reverse CART may be difficult to perform, necessitating the development of several facilitating techniques. One such technique is the use of large balloons over the antegrade guidewire. Another technique is the use of intravascular ultrasonography, which allows better understanding of the spatial relationship between the antegrade and retrograde guidewires, plaque morphology, vessel size, and allows selection of suitable size balloon for subintimal space dilation [4]. Still, recoil of the subintimal space may occur, even when adequately sized balloons are used. To solve this problem, several additional techniques were developed. The "stent reverse CART" technique involves deploying a stent over the antegrade wire in the subintimal space to create a target for the retrograde wire. Deploying a snare in the antegrade subintimal space can prevent recoil and facilitate retrograde wire crossing into the antegrade true lumen. However, "stent reverse CART" cannot be reversed, i.e. a deployed stent cannot be retrieved and the use of a snare can be cumbersome and expensive.In this issue of the Journal, Mozid et al. describe a novel and elegant modification of reverse CART, the "Guideliner reverse CART" [5] (Fig. 1b). A guide catheter extension is advanced over the antegrade guidewire, creating a new "target" for the retrograde guidewire to enter. This technique can achieve re-entry faster and safer ...

A novel maneuver to facilitate retrograde wire externalization during retrograde chronic total occlusion percutaneous coronary intervention

“…However, the retrograde wire can be manipulated in a true‐to‐true lumen fashion only in few cases, due to its tendency to engage in the subintimal space. In this context, reverse CART is currently the most frequently used retrograde CTO crossing technique . It has greatly facilitated retrograde wire re‐entry in the true lumen, since it is based on the balloon‐induced creation of a connection between the subintimal space and the true lumen .…”

The Canadian Contribution to Science, Techniques, Technology, and Education in Chronic Total Occlusion Percutaneous Coronary Intervention

“…From an era of dabbling with poorly selected guidewires bent with large radius curves, without contra-lateral guidance, and poor expected (and observed) results, we have successfully moved to an era where up-to-date standardized techniques and approaches are taught, encouraged, and available in most hospitals across the country. Canadian authors have contributed to the rapid expansion of information sources available to learn the hybrid approach, from consensus statements, 32,33 international research collaborations, [34][35][36][37][38][39][40][41][42] review articles, [43][44][45][46][47][48][49][50][51][52][53][54][55] editorial comments, 26,[56][57][58][59][60][61][62][63][64][65] case series or reports, [66][67][68][69][70][71][72][73][74] dedicated textbooks, 75 and as faculty in large dedicated CTO PCI conferences across the world. All sources of...…”

Use of the GuideLiner catheter for aspiration thrombectomy in a patient with ST-elevation myocardial infarction with a large intracoronary thrombus

“…However, these devices are not always effective because of the small diameter of the lumen. The GuideLiner catheter (Japan Lifeline, Tokyo, Japan) is used to achieve strong support with a guiding catheter [4][5][6], and delivery of various devices, including stents and balloons [7][8][9], in patients with coronary artery disease with heavy calcification, severe tortuousity, and chronic total occlusion [10,11]. This catheter is designed for the ''Mother and Child'' technique, with a rapid exchange system, and it is easy to handle because a second hemostat valve is not required.…”