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1.7 Retrograde Approach
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Fig. 1.175 Sites for
capturing a retrograde
guidewire with a snare
119
1.7.13 Kissing Wire Technique
parallel with the antegrade wire toward its entry point (even
if they are separated by a distance equal to the diameter of
I always try to perform antegrade PCI for CTO rst, and I
only switch to the retrograde approach after failure of this
initial attempt. During retrograde PCI, I direct the retrograde
guidewire toward the tip of the antegrade guidewire or near
the point where the antegrade wire entered the occlusion,
which means I am trying to cross the CTO by the kissing
wire technique.
For retrograde wiring of a long occlusion, the entry point
of an antegrade guidewire alone is not a reliable target. If the
antegrade guidewire has gone some distance into the occlusion, its tip is a better target for retrograde wiring. You should
not exactly target the tip of the antegrade guidewire, but
should advance the retrograde guidewire using little force in
Column 9 Techniques for the Middle and Distal RCA (Segments #2 and 3)
the vessel).
If the retrograde guidewire deviates into the subintimal
space near the proximal end of the occlusion, you should
direct the antegrade guidewire toward the retrograde wire to
cross the lesion by the kissing wire technique. PCI can be
accomplished successfully when either guidewire crosses
the CTO through the proximal or distal true lumen. If you
fail to achieve intraluminal crossing with both guidewires,
you should try reverse CART. As mentioned in the next
subsection, the kissing wire technique brings the antegrade
and retrograde guidewires close to each other, which means
that reverse CART can be successfully performed by using a
small balloon to dilate the space created by either guidewire.
The aim of the kissing wire technique is to cross a CTO through the proximal or distal true lumen with a retrograde or
antegrade guidewire by directing one guidewire (that appears to be within the true lumen) toward the other and bringing them into contact. However, it may be difcult to actually bring the two guidewires into contact or even to advance
the two wires parallel with each other. A typical example is a CTO in the middle segment (Segment #2) or distal segment (Segment #3) of the RCA that runs along the acute margin of the heart. The RCA runs in the atrioventricular
sulcus and has an acute bend at the acute margin of the heart. Its proximal segment runs along the anterior wall of the
right ventricle near the tricuspid valve, following a small arc toward the posterior side of the heart. At the acute margin
of the heart, the artery suddenly turns to the left and then runs relatively straight toward the crux. Absence of the right
ventricular branch and/or atrial branch in this region makes these bends of the RCA more acute and also makes this
part of the artery more mobile. Motion of the right atrium and ventricle is opposite during the cardiac cycle, which may
amplify movement of the RCA and also lead to unexpected movement.
An attempt to cross a CTO of the RCA (Segments #1 to 3) with an antegrade guidewire often fails because the wire
is unable to follow a tortuous part of the artery. When a retrograde guidewire is subsequently manipulated to cross the
CTO by using the kissing wire technique, it may also fail to navigate the tortuous region. Although I am an advocate
of “non-pushing PCI,” you cannot advance a guidewire without pushing it at all. Unless anchored in a side branch,
both the antegrade and retrograde guidewires will be directed toward the vertex of a bend when advanced into a tortuous lesion with even minimal force (Fig.1.176). If the tip of one guidewire becomes trapped in the vessel wall, pull it
back a little to reduce the angle of the bend, and then manipulate the other guidewire until it is parallel with the rst
wire. Then you should be able to advance the second guidewire relatively easily. If neither guidewire is trapped, you
should pull one guidewire back a little from its farthest position and then leave it at that site while manipulating the
other guidewire.
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bend in the vessel.
Conversely, before manipulating
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Before manipulating the retrograde
guidewire, you should pull the
antegrade guidewire back slightly
to reduce the angle of the
Fig. 1.176 Manipulating guidewires at a bend in the vessel
1 Mitsudo’s PCI Techniques forCTO
the antegrade guidewire, you
should pull the retrograde
guidewire back slightly.
1.7.14 Reverse CART Technique
The reverse CART technique was originally devised for the
situation where both the antegrade and retrograde guidewires
have entered a false lumen and are within a common compartment, as shown in Fig.1.135b. This technique involves
enlarging the false lumen and the true lumen near the proximal end of the occlusion by using the antegrade guidewire,
puncturing the intima to connect the two lumens, and advancing a retrograde guidewire along the connecting channel.
When this technique can be used, the retrograde guidewire
can always reach the proximal true lumen.
It should be noted that to successfully accomplish reverse
CART, the two guidewires must be within the space created
in a common compartment (Fig.1.177a) and should preferably be close to each other. If the two guidewires are distant
from each other, even if they are in a common compartment
(Fig.1.177b), the space created by inating a small balloon
after advancing it over the antegrade guidewire will not be
sufcient to accommodate the retrograde guidewire and will
need to be enlarged by using a larger balloon (Fig.1.177c).
However, ination of a larger antegrade balloon is more
likely to create a large dissection that evolves toward the distal end of the occlusion (Fig.1.178).
There are several ways of thinking about how to use the
reverse CART technique. Some studies have found comparable mid-term outcomes after placement of a drug-eluting
stent (DES) in a false lumen versus the true lumen for recanalization of CTO. Possibly based on this evidence, some
interventionalists intentionally advance an antegrade guidewire into the subintimal space from the proximal side of an
occlusion if the retrograde guidewire has entered the subintimal space near the proximal end of the occlusion.
In the bare-metal stent (BMS) era, higher rates of restenosis and aneurysm were reported after recanalization of CTO
by stenting a false lumen compared with the true lumen.
The outcome achieved with DES may be different, and it
may be suggested that what will happen after an intervention cannot be predicted without trying it. However, I think
we should generally avoid strategies that achieved poor outcomes with BMS when using DES.It is true that we can only
determine the eventual outcome of PCI for CTO after longterm follow- up and that a strategy which was ineffective
with BMS may have a good outcome when employed with
DES. Unfortunately, this means that we can only nd the
truth after a long time and yet we have to make choices when
nobody knows the outcome. Thus, I consider that it is better
to avoid strategies achieving a poor outcome with BMS when
using DES, at least for the present. When performing PCI
for CTO by the reverse CART technique, I always carefully
target the true lumen with both the antegrade and retrograde
guidewires (kissing wiring), aiming to create a connecting
channel between the antegrade and retrograde “true lumens”
(“true lumen” reverse CART technique).
Despite such efforts, most attempts at CTO recanalization
by the reverse CART technique lead to one of the following
outcomes:
1. Both the antegrade and retrograde guidewires enter the
subintimal space and miss the true lumen, passing through
a common subintimal space on the way to the proximal/
distal ends of the occlusion.
a
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121
2. Both the antegrade and retrograde guidewires eventually
enter the subintimal space and miss the true lumen, but
pass through the true lumen at some point on the way to
the proximal/distal ends of the occlusion. To achieve
“true lumen” reverse CART, I always aim to maximize
the distance for which the wires are in the true lumen
while crossing the occlusion.
After approximating the two guidewires as closely as pos-
sible by the kissing wire technique, you should use either
wire to advance and inate a balloon with a diameter corresponding to the distance between the two wires. This will
help the two guidewires to enter a common space created by
the balloon.
Keeping the antegrade and retrograde guidewires within
a common space is an important requirement for successful reverse CART, but it may sometimes be difcult to
introduce the retrograde guidewire into the proximal true
lumen even if this requirement is met. A typical cause of
failure is that the dissection created by balloon ination
extends to the proximal true lumen (Fig.1.178) and may
compress the intimal connection between the false and true
lumens soon after ballooning or lead to deformation of
the tip curve of the guidewire. Enlargement of the dissection and resultant compression may conne the guidewire
within the subintimal space and prevent it from entering
the true lumen.
It is also difcult to attempt reverse CART if the antegrade
and retrograde guidewires have entered different dissections after being blocked by a hard obstruction in an occlusion (Fig.1.179). Advancing the retrograde guidewire while
leaving the deated balloon in position to prevent closure of
the connecting channel may sometimes be effective in this
situation, while withdrawing the deated balloon to further
enlarge the space may also be worth trying. Furthermore,
inating a larger balloon to enlarge the common space and
the new connection can help the retrograde guidewire to
cross the occlusion into the proximal true lumen. The key
to success with reverse CART is to advance the tip of the
retrograde guidewire toward the proximal end of the occlusion alongside an antegrade balloon and/or guidewire. If
reentry of the retrograde guidewire from the dissection is
not achieved despite these efforts, it may be facilitated by
IVUS-guided retrograde wiring after conrming the location of the new connection. If this is also ineffective, you
should implant a stent under IVUS guidance so that its distal end is within the common space accommodating the two
guidewires (Fig.1.180). The length of the stent should be
determined by estimating the distance from the proximal to
the distal points by IVUS.If this distance is estimated incorrectly and the stent selected is too short, another stent will
also need to be implanted to overlap the rst stent within
the false lumen. This is a disadvantage of the stent reverse
CART technique.
When performing reverse CART, the retrograde guidewire that passes through the occlusion has too high a tip load
and too small a tip curve to reenter the proximal true lumen.
Therefore, you should advance a retrograde microcatheter
into the occlusion until it reaches the tip of the antegrade balloon (or advance the antegrade balloon instead) (Fig.1.181),
and subsequently exchange the retrograde guidewire for a
wire with a lower tip load and greater slipperiness. The new
guidewire will successfully follow the channel from the false
lumen to the true lumen.
Fig. 1.177 Reverse CART
technique. (a) If the antegrade
and retrograde guidewires are
close to each other, inating
even a small antegrade
balloon will lead to successful
accomplishment of the
reverse CART technique. (b)
If the two guidewires are far
apart, even within a common
compartment, it is very
difcult to accomplish reverse
CART by inating a small
antegrade balloon. (c)
Inating a larger antegrade
balloon will lead to successful
accomplishment of reverse
CART, but inevitably creates
a large dissection
b
c
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stenting
Accomplishing
reverse CART
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Fig. 1.178 Dissection created by the reverse CART technique.
Successful accomplishment of the reverse CART technique requires
enlargement of a false lumen, which inevitably creates a dissection of
some size. Use of a large balloon will create a large dissection, which
can compress or distort the distal true lumen if it extends distally
1 Mitsudo’s PCI Techniques forCTO
Fig. 1.179 If kissing reverse CART is impossible. If hard plaque in an
occlusion blocks the antegrade and retrograde guidewires, causing
deviation in different directions, you should search for a more proximal
point where the two wires are close to each other to accomplish reverse
CART
Fig. 1.180 Stent reverse
CART technique. If a large
dissection is created and it
prevents the retrograde
guidewire from passing
through a connecting channel
created between the false
lumen and the true lumen,
you should place a stent in the
space accommodating both
guidewires (as conrmed by
IVUS) and then introduce the
retrograde guidewire into the
stent
true
false
Both wires are in
the same false
lumen in this segment
Distal limit of
stenting
(confirmed by IVUS)
Large dissection Introducing the retrograde gudewire from
false lunen to true lumen by using IVUS
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Fig. 1.181 Recanalization of a CTO by reverse CART.Before attempt-
ing reverse CART, you should exchange the retrograde guidewire for
another with greater slipperiness. Reverse CART can be accomplished
1.7.14.1 Kissing Reverse CART
Even after a previous failed PCI attempt, I always start PCI
for CTO via the antegrade approach under appropriate circumstances, and I switch to retrograde PCI after an antegrade
guidewire has failed to reach the distal true lumen. There are
two patterns for failure of antegrade wiring. First, the antegrade guidewire may fail to reach the distal end of the CTO
because advancement within the occlusion becomes impossible or because the wire deviates outside the vessel wall.
Second, the antegrade guidewire may reach the distal end of
the occlusion, but its tip may be outside the true lumen.
Immediately before starting retrograde PCI, you should
perform contralateral CAG to conrm that a collateral channel
is available. After a retrograde guidewire and then a retrograde
microcatheter have successfully tracked the collateral channel, you can try to cross the CTO retrogradely by using the
antegrade guidewire as a landmark (kissing wire technique).
Why should you try the kissing wire technique despite the
eventual need to perform reverse CART? Here, let us reconsider the denition of reverse CART.CART is an acronym
for controlled antegrade and retrograde subintimal tracking,
and it can only be accomplished if both the antegrade and retrograde guidewires are within a common subintimal/subadventitial space (see Fig.1.135c). Reverse CART is similar to
CART, with the only difference between the two techniques
being that the subintimal space is enlarged by a balloon
introduced antegradely (not retrogradely) when performing reverse CART.As enlargement of the subintimal space
is needed anyway, intentionally advancing both guidewires
if the retrograde guidewire is manipulated in the segment where the two
guidewires have been brought into contact (dotted line)
into the subintimal space from both ends of the occlusion
saves time. The safest and most efcient way of advancing a guidewire into the subintimal space is to manipulate
a knuckled guidewire from the proximal or distal end of the
occlusion (Fig.1.182). However, this will lead to complete
subintimal tracking, resulting in subintimal stenting for the
full length of the CTO.Although many recent studies have
reported no increase in the mid-term risk of adverse events
after subintimal stenting with a DES, subintimal stenting
clearly had worse outcomes in the BMS era, and no data are
available about the long-term outcome of subintimal stenting
using DES.In addition, subintimal stenting is incompatible
with vascular physiology and not in harmony with nature.
Hence, my current PCI strategy for CTO involves implanting
a stent in the true lumen whenever possible.
I did not notice that I have never used the original reverse
CART technique until it was pointed out by others. In fact,
the “reverse CART technique” that I use does not t the original denition and perhaps should rather be referred to as the
“kissing reverse CART technique.”
Performance of kissing wiring does not rule out the possibility that both the antegrade and retrograde guidewires
have passed through the true lumen in at least part of the
CTO.Reverse CART is primarily attempted when the antegrade and retrograde guidewires fail to enter the true lumen
at the distal and proximal ends of the occlusion, respectively
(Fig.1.183a). This technique is also used when it becomes
impossible to advance one or both of the guidewires within
a CTO (Fig.1.183b).
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1 Mitsudo’s PCI Techniques forCTO
To accomplish reverse CART, the antegrade and retrograde guidewires have to be in a common compartment
that can be enlarged by a balloon. Prior use of the kissing
wire technique helps to conrm that the two guidewires are
in a common compartment. That is, if the two guidewires
can be brought into contact anywhere in an occlusion, the
wires are located in the same compartment (Fig. 1.181).
Simultaneous imaging in two orthogonal projections makes
it easy to alter the direction of a guidewire and advance it
toward the other wire and to conrm that the two wires
are in contact (Fig. 1.181). Multidirectional imaging or
rotational imaging using single plane cineangiography
can also facilitate conrmation of contact between the two
guidewires, but cannot provide assistance for correcting the
guidewire direction in a real-time manner to achieve contact. This is one reason for the importance of being able
to perform simultaneous anteroposterior and lateral imaging with biplane cineangiography. If it is conrmed that
the two guidewires are in the same compartment, reverse
CART can be accomplished. If the shared compartment is
the true lumen and not a false, the technique should not be
referred to as “controlled antegrade and retrograde subintimal tracking,” but as “controlled antegrade and retrograde
true lumen tracking.”
If the two guidewires are brought into contact with each
other in the true lumen, continuing to advance either wire
in the same direction may result in crossing the occlusion into the proximal or distal true lumen. We can classify such a method of CTO crossing as direct antegrade or
retrograde crossing using the contralateral guidewire as a
landmark.
If it proves impossible to bring the two guidewires into
contact, it is generally reasonable to conclude that the wires
are in different compartments. If one of the guidewires has
been advanced along a relatively straight course without an
inection point and the other guidewire takes a spiral course
around the former wire, it is reasonable to think that the former wire is in the true lumen and the latter wire is tracking a
false lumen (Figs.1.184 and 1.185).
It may be difcult to bring two guidewires in the same
compartment into contact under some circumstances, including the following situations:
1. The two guidewires are within the same subintimal space
but are far apart because the vessel has a large diameter
(see Fig.1.177).
2. The two guidewires are inside plaques in the true lumen
of a large vessel that has undergone positive remodeling
(Fig.1.186).
3. When the CTO is located in the middle to distal segments
of the RCA (Segments #2/3) at the acute margin of the
heart (see Fig.1.176).
Under these circumstances, you should advance the two
guidewires with great care by using the kissing wire technique to bring them into contact. Then it is often possible to
accomplish reverse CART after ination of a large balloon.
In some cases (e.g., when reattempting PCI), the antegrade
subintimal space (dissection) is too large (e.g., with retry) to
allow the stabilization of the tips of the two guidewires so
that they can be brought into contact (Fig.1.187).
Thus, I think that you should aim to introduce both guidewires into the true lumen whenever possible when using
the kissing wire technique, and you should only try reverse
CART if the kissing wire technique fails.
Fig. 1.182 Knuckle wire
ab
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Fig. 1.184 Information from the courses of two guidewires. If one
guidewire follows a spiral course and the other follows a relatively
straight course, the latter wire is likely to be within the true lumen
Fig. 1.183 When to switch to the reverse CART technique. (a) When
a retrograde guidewire fails to enter the true lumen. (b) When at least
one guidewire is blocked by hard plaque and cannot be advanced any
further
Fig. 1.185 CTO of the distal RCA.In this CTO of the distal RCA, the
antegrade guidewire follows a spiral course, and the retrograde guidewire is straight. Therefore, the antegrade guidewire may have entered a
false lumen, while the retrograde guidewire has probably tracked the
true lumen. To achieve successful recanalization of the lesion, you
should advance the retrograde guidewire further with the aim of performing direct retrograde crossing, or you could attempt reverse CART
at the proximal part of the occlusion
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1 Mitsudo’s PCI Techniques forCTO
a
b
cd
Fig. 1.186 CTO in a large RCA.The RCA has a large diameter proxi-
mally and is moderate in size at the distal bifurcation, so the occlusion
will also have a large diameter (a). Reverse CART failed when it was
Fig. 1.187 Kissing wire technique in a large dissection. It is difcult
to bring the two guidewires into contact when the wires are inside a
large dissection
attempted with a small balloon (b), but was accomplished successfully
after ination of a large balloon (c). CAG after dilation of the lesion (d)
Contemporary Reverse CART Technique
I will discuss the role of antegrade ballooning based on my
PCI strategies for CTO that are summarized in Table1.9. The
contemporary reverse CART technique was rst advocated
by Dr. Osamu Kato around 2013. If the concept described
below can be accepted (which is slightly different from the
original concept), contemporary reverse CART can be considered an extension of the kissing wire technique.
The contemporary reverse CART technique can be summarized as follows. When an antegrade guidewire fails to
reach the distal true lumen or is blocked within an occlusion, a balloon with a small diameter of about 2.0 mm is
advanced along the antegrade guidewire and inated within
the occlusion (Fig.1.188a), while the retrograde guidewire
is advanced directly through the occluding tissue toward the
1.7 Retrograde Approach
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127
balloon (Fig.1.188b). Subsequently, the balloon is deated,
and the retrograde guidewire is advanced alongside the balloon until it is introduced into the enlarged proximal space
(Fig.1.188c).
Contemporary reverse CART has the following advantages over classical reverse CART: (1) no enlargement of a
distal dissection, (2) the antegrade balloon provides a better landmark when using a retrograde guidewire to connect
the antegrade and retrograde spaces, (3) intimal puncture to
reach the antegrade balloon can even be done from a different compartment, (4) IVUS guidance is not required, and (5)
the procedural time is shorter.
When kissing reverse CART is performed, the antegrade
and retrograde guidewires need to be within a common compartment. However, even if the two guidewires are close to
each other, they sometimes fail to enter a common space
after ination of an antegrade balloon with a small diameter
such as 2.0 or 2.5mm, as shown in Fig.1.189. When treating
a long CTO, if the antegrade and retrograde guidewires have
passed through the same lumen (even if it is a false lumen),
a non-stiff retrograde guidewire can often be advanced into
the space enlarged by an antegrade balloon; if not, a nonstiff retrograde guidewire often cannot be introduced into the
space. On the other hand, it is difcult to advance a stiff CTO
crossing guidewire into the space created by the antegrade
balloon without IVUS guidance, and it may even be difcult
under IVUS guidance. Eventually, you may nd it necessary to use a large balloon to enlarge the space created by
the antegrade guidewire or else search for another segment
where the two guidewires are in the same compartment.
Why would two guidewires that are apparently very close
to each other fail to enter a common space? As shown in
Fig. 1.190, despite the two guidewires being in the same
compartment, the antegrade balloon may be inated in the
opposite direction to that for advancement of the retrograde
guidewire, or else the two guidewires may be close to each
other but actually within different compartments.
When the two guidewires are in the same compartment
or an antegrade balloon is in a false lumen, ination of the
antegrade balloon will occlude the proximal false lumen and
allow the retrograde guidewire to be deected, so you can
advance the guidewire toward the balloon (Fig.1.191).
If a stiff CTO crossing guidewire (a Gaia Second or
Conquest Pro 12) can be advanced from the retrograde direction toward an antegrade balloon that has been inated, the
guidewire may enter the space created by the balloon. Biplane
cineangiography in two orthogonal projections around the longitudinal axis of the balloon (the tip of the retrograde guidewire should be located at the center of the transverse section of
the balloon in one projection, and the guidewire tip should be
most distant from the balloon in the other) will facilitate successful navigation of the guidewire to the balloon (Fig.1.192).
While the presence of calcied plaque or any other
hard obstruction in an occlusion may have some effect, the
ease of accomplishing reverse CART largely depends on
the combination of compartments occupied by the antegrade and retrograde guidewires/balloon (Fig. 1.191 &
Table1.10).
I sometimes use contemporary reverse CART as the nal
step of the kissing wire technique. I particularly prefer this
technique when a retrograde microcatheter cannot reach the
tip of the antegrade guidewire so that I cannot exchange the
retrograde guidewire for another with a lower tip load to
accomplish classical reverse CART.
Another situation where contemporary reverse CART
may be used is shown in Fig.1.193. This is one of the settings that will most likely preclude accomplishment of
reverse CART.That is, the two guidewires pass through the
same compartment (the subintimal space) for only a short
distance, with the retrograde guidewire changing direction
toward the true lumen immediately after entering the subintimal space and passing through a small channel to the proximal true lumen. As the dissection may sometimes extend to
the proximal part of the vessel, even a non-stiff guidewire
will be unable to pass through the channel. In this situation,
the contemporary reverse CART technique may be effective
if it attempted slightly more distally (Fig. 1.193). The retrograde guidewire can be advanced through the subintimal
space and enter the connecting channel to the true lumen
more proximally, making it easier to abruptly change direction toward the channel.
Retrograde wiring toward an antegrade balloon (plus
reverse CART) may be a successful strategy for recanalization of many CTOs. However, it is often difcult to use this
technique if the antegrade guidewire is in the true lumen
and the retrograde guidewire is in a false lumen. If it is difcult to accomplish reverse CART, you should suspect one
of the abovementioned circumstances. Then you should
advance a guidewire antegradely as far as possible into the
CTO by any method (e.g., using a stiff antegrade guidewire) to try to nd a true-true lumen route or you should
aim for retrograde reentry into the true lumen within the
occlusion by any method (e.g., using a stiff retrograde
guidewire) (Fig.1.194).
Table 1.9 My basic PCI strategies for CTO
Collateral channel status
Few channels available There is a trackable channel
– Antegrade true lumen
crossing
– True lumen crossing by
seesaw wiring
– Attempt retrograde PCI
– IVUS-guided wiring
– Antegrade true lumen crossing
– True lumen crossing by the kissing
wire technique
– Reverse CART technique
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abc
ab
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1 Mitsudo’s PCI Techniques forCTO
Fig. 1.188 Reverse CART technique. (a) The proximal part of the
occlusion is dilated by inating a small antegrade balloon. (b) A retrograde guidewire is advanced to bring it into contact with the antegrade
balloon. (c) The balloon is deated, and the retrograde guidewire is
introduced into the space
Fig. 1.190 Situations that
prevent success with the
reverse CART technique. (a)
Hard plaque in the true lumen
blocks the retrograde
guidewire and prevents it
from reaching the space
created by ination of an
antegrade balloon. (b) The
two guidewires are close to
each other, but are in different
compartments, making it
impossible to accomplish
reverse CART
Fig. 1.189 Kissing reverse CART technique. If the antegrade and ret-
rograde guidewires are in the same compartment, reverse CART can be
accomplished, since even a non-stiff guidewire can enter the space created by the antegrade balloon
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