Case 254: Manual of CTO PCI - CART

A patient with prior CABG surgery was referred for PCI of a native RCA CTO due to recurrent failure of the SVG-PDA. Coronary CT angiography was done prior showing the proximal cap to be at the takeoff of an acute marginal branch, length of 34 mm, and calcification at the proximal cap and within the occlusion segment. A primary retrograde approach was used with a Pilot 200 wire advanced through a Corsair 200 microcatheter but the wire entered the extraplaque space at the proximal cap. Antegrade wiring was attempted using the retrograde wire as marker, but the antegrade wires kept on also entering into the extraplaque space. A 2.5 mm balloon was advanced retrogradely through the SVG to the proximal cap, followed by successful antegrade wiring (CART technique) with a nice result after stenting.

[@shangz0216]

Thanks for the excellent case sharing.

[@dmxspark]

Thanks sir

[@krishnasagar2342]

Thank you for the great case Professor. Is there a risk of thrombi showering into the native vessel from the coiled SVG graft Professor?

[@wilzboyz]

No

[@apurvavasavada383]

Is it mandatory to occlude the SVG?

[@wilzboyz]

@@apurvavasavada383 no but if there’s significant competitive flow from the graft the risk of stent thrombosis is higher, theoretically. No data. Just anecdotal experience. On the downside it removes a conduit to fix a CTO in the future. IMO depends on the degree of competitive flow.