Wire externalisation techniques for retrograde percutaneous coronary interventions of chronic total occlusions

Simple Techniques for Antegrade Guiding Catheter Engagement after Retrograde CTO Crossing

“…e antegrade conversion of the procedure with the catch-it maneuver can avoid wire snaring in the aorta or brachiocephalic trunk and can be followed by a safe antegrade microcatheter probing [7], as in our case, alternatively replaced by a rendezvous [9] or a tip-in [10] attempt whenever unsuccessful, holding a good compromise between interventional success and patient's safety. As a bailout, retrograde externalization [8] through the radial sheath can still be performed by advancing a >300 cm dedicated wire, as we discussed above, and it requires no guide engagement maneuver (catch-it or snaring) at all.…”

“…More recently, as an alternative to externalization [8], a so-called antegrade microcatheter probing has been proposed, by which the retrograde microcatheter, whose distal tip is positioned into the distal curve of the antegrade guiding catheter, is approached antegradely by a workhorse wire trying to enter its distal orifice [7]. is strategy allowed for the antegrade conversion in our case (see Video 4 in Supplementary Material), finally completed by the implantation of three drug-eluting stents with a good angiographic result of the RCA (Figure 1(d)) and without any procedural and postprocedural complications.…”

“…Antegrade guiding catheter engagement with the retrograde wire in a large vessel, such as the aorta or subclavian artery Tip-in [10] Retrograde wire insertion into the tip of an antegrade microcatheter, usually in the distal curve of the antegrade guiding catheter; usually when the retrograde microcatheter cannot pass the lesion and enter the antegrade guiding catheter Rendezvous [9] Antegrade guidewire, supported by an antegrade microcatheter, inserted into the retrograde microcatheter that has crossed the lesion. e two microcatheters meet in the guiding catheter Antegrade microcatheter probing [7] Intubation of the retrograde microcatheter with an antegrade workhorse wire in the distal curve of the antegrade guiding catheter Wire trapping techniques [6,7] Trapping of the tip of the retrograde wire in the distal part of the antegrade guide by the inflation of an antegrade balloon (reverse anchoring balloon [7]) or antegrade snare [6] Reverse wire trapping [11] Antegrade microsnare grabbing the retrograde wire in the antegrade guiding catheter in order to pull the snare through the occlusion and exchange it with an antegrade guidewire Externalisation [8] Use of dedicated ≥300 cm externalization wires, entering the retrograde microcatheter and running through the occlusion to be pushed or pulled out contralaterally and allow the antegrade conversion of the procedure and entering an antegrade guide catheter externalization via the radial sheath may be an alternative option. Notably, some catheter shapes may be unsuitable for the aortic catch-it, but they still may work in a subclavian procedural setting.…”

When antegrade microcatheter does not follow: The “facilitated tip‐in technique”

“…This can be performed within the antegrade guiding catheter, within the CTO lesion or at the proximal CTO cap. 3,4 In our case, a primary retrograde approach was used considering the occlusion length, the blunt stump, the poor landing zone, and the good collateral circulation of the CTO. After a successful lesion crossing with R-CART technique, at the very last step of tip-in technique for wire externalization, we were able to advance the antegrade Caravel 135 only to mid LAD due to the lack of antegrade support, which was solved by the insertion of an extra-guidewire into the antegrade MC.…”

Current approaches for treatment of coronary chronic occlusions

“…In case of unfavorable anatomy alternative techniques should be considered. The tip-in technique consists in the advancement of an antegrade microcatheter followed by the insertion of the retrograde guide-wire in the tip of the antegrade microcatheter that can be further advanced up to the distal cap finalizing the procedure antegradely [80].…”