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168 PART IV Wires Technique
Figure 18.1 Management of collaterals in retrograde chronic total occlusion percutaneous coronary intervention. CTO:
chronic total occlusion; PCI: percutaneous coronary intervention; PJ: polymer jacketed
at low pressure (2–4 atm) (only with septal collaterals). Finally, if all measures fail, the crossed collateral may have to be given up on and another one
crossed.
4) Crossing the CTO
Retrograde CTO crossing can be performed in one of
two ways – (1). Retrograde wiring (RW) (2). Retrograde
Dissection Reentry (RDR).
1) Retrograde wiring
Retrograde intraplaque crossing is usually successful
with short, straight, non-calcified occlusions. The
wire escalation/de-escalation technique is like antegrade wiring except for negotiating a softer cap (distal
cap is exposed to lower pressure except in prior bypass
patients), and with less support, given the transmission of power through the collateral.
2) Retrograde dissection and re-entry
The main techniques to perform RDR include controlled antegrade and retrograde tracking (CART),
reverse CART, or double-balloon technique. The
most used approach is reverse CART, where a balloon
is inflated over the antegrade wire, followed by retrograde guidewire advancement into the space created
by the balloon. Multiple iterations of the reverse
CART technique have been developed to facilitate the
procedure (Figure 18.2). In classic reverse CART, an
oversized balloon is used antegrade to create the connection with the retrograde wire. In contemporary
reverse CART, a small antegrade balloon is inflated,
and a directional wire is used retrograde to cross. The
technique is most useful when both wires are in the
same space (intraplaque or extraplaque). Guideextension reverse CART depends on advancing an
antegrade guide-extension to approximate the target
and facilitate crossing [24]. Finally, specialty balloons
or laser assisted reverse CART depends on inflating a
specialty balloon antegrade (e.g., cutting balloon,
Shockwave balloon (Shockwave, US), etc.) or laser
atherectomy device to aggressively connect the spaces
[25]. Ideally to minimize the length of sub-intimal or
extra plaque stenting, the connection should be made
within the CTO body. However sometimes this is not
possible in which case the extended reverse CART
technique is useful, where reentry into the true lumen
occurs outside the body of the CTO.
In reverse CART failure, the first step is to use a
larger antegrade balloons to connect spaces. If this
fails, the next step is to perform IVUS over the antegrade wire to understand the relationship between the
antegrade and retrograde wires. Four relationship
possibilities exist. If both wires are in the same space
(intraplaque or extraplaque), a bigger balloon and a
CHAPTER 18 Retrograde CTO PCI: Step by Step 169
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Figure 18.2 Variations and troubleshooting of the reverse controlled antegrade and retrograde tracking (reverse CART).
CART: controlled antegrade and retrograde tracking; IVUS: intravascular ultrasound; PJ: polymer jacketed
retrograde soft polymer jacketed wire can be used. If
the antegrade wire is intraplaque while the retrograde
wire is extraplaque, a bigger antegrade balloon can
tear the intima and connect the spaces. Retrograde
directional stiff wire can be utilized in this case.
Finally, if the antegrade wire is extraplaque and the
retrograde wire is intraplaque, using a bigger balloon
might not solve the problem. The operator can try to
use a retrograde directional stiff wire to puncture into
the subintimal space guided by the antegrade balloon.
The retrograde wire can also be advanced until it
crosses or travels to the extraplaque space, where creating a connection can be easier established. Finally,
the operator can reattempt retrograde wiring into the
extraplaque space with a knuckle.
In rare cases r-CART is not possible and resorting
to the old method of sending a balloon over the retrograde wire is necessary. This is called CART. CART is
mainly used when a balloon cannot be advanced on
the antegrade wire.
(5) Treating the CTO
The next step is retrograde wire externalization,
which is performed by advancing the guidewire and
microcatheter into the antegrade guide, and the retrograde wire is replaced with a long externalization wire
(e.g., R350 (Vascular solutions, US) or RG3 (Asahi
170 PART IV Wires Technique
Intecc, Japan)). The microcatheter should always protect the collateral channel during manipulation of the
retrograde wire. To prevent inadvertent loss of the retrograde wire, it can be pinned with a torque or a
clamp. If microcatheter advancement into the antegrade guide is not possible then the first maneuver is
to pin or trap the retrograde wire in the antegrade
guide that would allow for advancing the microcatheter into the antegrade guide. The second option is the
“tip in” technique. In this, a microcatheter is advanced
within the antegrade guide and at the highest point of
the aorta on the outer curve of the guiding catheter,
the retrograde wire has a very high chance of going
straight into the microcatheter. This then allows for
advancement of the antegrade microcatheter over the
retrograde wire and conversion of the case from a retrograde to an antegrade case.
Treatment of the CTO is performed with angioplasty
and stenting over the externalized wire. If the risk
of being retrograde is high because of donor vessel
ischemia, switching to the antegrade approach might
be reasonable.
(6) Removal of retrograde gear
Removal of retrograde gear should be performed in a
systematic fashion to avoid complications. First, the
retrograde microcatheter is re-advanced into the antegrade guide catheter or at least into the stented segment
of the CTO to avoid the shearing effect of withdrawing
the retrograde wire on the CTO vessel or collateral
channels. This is followed by disengagement of the
antegrade and retrograde guides. The retrograde wire is
withdrawn into the collateral channel, and the microcatheter is pulled back, leaving the wire in place until a
retrograde angiogram is performed to check for any
collateral channel perforation. If no perforation is identified, the microcatheter is readvanced, and the wire is
removed.
Collateral perforation is one of the unique complications of the retrograde approach. Epicardial collateral
perforation leading to hemodynamic collapse from
tamponade is the most challenging complication to
manage because the collateral channel requires
management from both the antegrade and retrograde
limb. In the OPEN CTO registry, all 8 epicardial collateral perforations cases had clinical consequences and
were associated with a significant risk of adverse events
and death [26]. A tip injection through the microcatheter can be obtained to exclude perforations if a high
index of suspicion exists for one. If a perforation is
identified, rapid measures should be taken, including
an echocardiogram, pericardiocentesis, and immediate
sealing of both ends of the collateral using fat, coils, or
thrombin.
On the other hand, septal collateral perforations are
mostly benign and only rarely lead to septal hema-
tomas, impeding ventricular filling [27]. If a perforation is deemed clinically relevant with septal
perforator branches, it can be managed in the same
way as an epicardial collateral perforation. Use of contrast echocardiography is a useful technique to identify ongoing bleeding after primary treatment has
been completed. Being facile with all aspects of perforation management is critical to the safe performance
of retrograde CTO PCI.
Conclusion
Knowledge of the retrograde skill set is vital in contemporary CTO PCI. Proper case selection and a stepwise approach to treatment are necessary for
programmatic success and avoidance of complications. Mentoring and proctored cases early in the
experience of the operator are crucial to set up a successful CTO program.
Abbreviations
CTO: chronic total occlusion
PCI: percutaneous coronary intervention
GW: guidewire
RA: retrograde approach
RW: retrograde wiring
RDR: retrograde dissection reentry
References
1 Kahn JK, Hartzler GO. Retrograde coronary angioplasty
of isolated arterial segments through saphenous vein
bypass grafts. Cathet Cardiovasc Diagn 1990; 20: 88–93.
2 Silvestri M, Parikh P, Roquebert PO, Barragan P, Bouvier
JL, Comet B. Retrograde left main stenting. Cathet
Cardiovasc Diagn 1996; 39: 396–399.
3 Ozawa N. A new understanding of chronic total occlusion
from a novel PCI technique that involves a retrograde
approach to the right coronary artery via a septal branch
and passing of the guidewire to a guiding catheter on the
other side of the lesion. Catheter Cardiovasc Interv 2006;
68: 907–913.
4 Megaly M, Buda K, Mashayekhi K et al. Comparative anal-
ysis of patient characteristics in chronic total occlusion
revascularization studies: trials vs real-world registries.
JACC Cardiovasc Interv 2022; 15: 1441–1449.
5 Megaly M, Xenogiannis I, Rafeh NA et al. Retrograde
approach to chronic total occlusion percutaneous coronary
intervention. Circ Cardiovasc Interv 2020; 13: e008900.
6 Kalra S, Doshi D, Sapontis J et al. Outcomes of retrograde
chronic total occlusion percutaneous coronary intervention: a report from the OPEN-CTO registry.Catheter
Cardiovasc Interv 2021;97:1162–1173.
7 Megaly M, Ali A, Saad M et al. Outcomes with retrograde
versus antegrade chronic total occlusion revascularization. Catheter Cardiovasc Interv 2020; 96: 1037–1043.
CHAPTER 18 Retrograde CTO PCI: Step by Step 171
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8 Brilakis ES, Grantham JA, Rinfret S et al. A percuta-
neous treatment algorithm for crossing coronary
chronic total occlusions. JACC Cardiovasc Interv 2012;
5: 367–379.
Maeremans J, Walsh S, Knaapen P et al. The hybrid
9
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Tanaka H, Tsuchikane E, Muramatsu T et al. A novel
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occlusion. J Am Coll Cardiol 2019; 74: 2392–2404.
11
Galassi A, Werner G, Boukhris M et al. Percutaneous
recanalization of chronic total occlusions: 2019 consensus
document. EuroIntervention.2019 Jun 20;15(2):198-208
Harding SA, Wu EB, Lo S et al. A new algorithm for
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crossing chronic total occlusions from the Asia Pacific
Chronic Total Occlusion Club. JACC Cardiovasc Interv
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Meah MN, Ding WY, Joseph T, Hasleton J, Shaw M,
Palmer ND. Complex chronic total occlusion revascularization – a comparison of biradial versus femoral access.
J Invasive Cardiol 2021; 33: E52–E58.
Sandoval Y, Burke MN, Lobo AS et al. Contemporary
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15 Brilakis ES, Mashayekhi K, Tsuchikane E et al. Guiding
principles for chronic total occlusion percutaneous coronary intervention: a global expert consensus document.
Circulation 2019; 140: 420–433.
16 Werner GS, Ferrari M, Heinke S et al. Angiographic
assessment of collateral connections in comparison with
invasively determined collateral function in chronic
coronary occlusions. Circulation 2003; 107: 1972–1977.
17
Huang -C-C, Lee C-K, Meng S-W et al Collateral channel
size and tortuosity predict retrograde percutaneous coronary intervention success for chronic total occlusion.
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Dautov R, Manh Nguyen C, Altisent O, Gibrat C, Rinfret
18
S. Recanalization of chronic total occlusions in patients
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report of right ventricular compression from a septal
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19
CHAPTER 19
Retrograde CTO Intervention via
Vein Grafts
Pavan Reddy & Nelson L. Bernardo*
Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
*Corresponding author
Introduction
Chronic total occlusion percutaneous coronary intervention (CTO-PCI) is more likely to be performed in a
patient with previous coronary artery bypass grafting
(CABG) than without [1].This may be due in part to a
selection bias, given that a cohort of CABG patients
likely maintain a propensity toward more severe coronary artery disease. It has also been shown that bypass
grafting may have an accelerating effect on the progression of atherosclerotic disease severity in the bypassed
native coronary artery [2]. In a randomized control trial
of angioplasty vs. CABG, 36% of native arteries that
were bypassed became totally occluded, while only 2.5%
were occluded after angioplasty [2]. Another study
found that 43% of bypassed native vessels became
occluded at one year [3]. Moreover, vein grafts are notoriously unreliable as a bypass conduit. In one study, the
venous bypass graft becomes occluded at a rate of 40%
at one year [4]. Thus, operators may often encounter
patients with ischemic myocardial territories due to
both native artery and graft occlusion. In these cases,
re-operation is an option but often involves prohibitively high surgical risk. Percutaneous coronary intervention (PCI) of vein grafts may be considered but
should be weighed against increased stroke risk and
higher in-hospital mortality [5, 6]. CTO-PCI is an alternative option, with recent studies suggesting that a
“hybrid” approach, employing strategies of antegrade or
retrograde wire escalation and dissection/reentry, are
useful to achieve technical and procedural success [7, 8].
A retrograde approach may proceed through collateral
channels, as well as patent or occluded bypass grafts.
Few studies have documented experience with
CTO-PCI using the saphenous vein graft (SVG) as the
retrograde access. However, contemporary literature
does demonstrate its safety and efficacy [1, 9–11]. One
observational study found that retrograde CTO intervention via vein grafts, in comparison to collateral
approach, had higher technical (85% vs. 78%; p = 0.04)
and procedural success (81% vs. 74%; p = 0.04). The
vein graft cohort also required less contrast volume,
and there was no difference in in-hospital adverse
events, despite a higher PROGRESS-CTO score [11].
Given the observational nature of this study, questions
arise regarding the anatomical or clinical factors that
guided operators toward their chosen approach.
Further, there is no comparison to the traditional antegrade approach. Dautov et al. provide some insight
into the latter issue, albeit a cursory assessment due to
small sample size. In their study, the group first
describes differences in outcomes among patients who
undergo CTO intervention with vs. without prior
CABG. They then go on to analyze procedural outcomes between the different CTO approaches in
CABG patients, that is, antegrade vs. retrograde via
vein graft vs. retrograde via collaterals. High success
rate was noted for all three approaches (90–93%) at a
cost of higher contrast use and fluoroscopy time in the
retrograde groups. The retrograde groups also had a
higher proportion of proximal cap ambiguity, longer
lesions or bifurcation at the distal cap, and high J-CTO
(Multicenter CTO Registry of Japan) scores [1].
Approach to retrograde SVG CTO
intervention
The retrograde SVG approach may be pursued
after considering several anatomic case attributes.
Antegrade approach is generally prioritized; how-
Chronic Total Occlusions: A Guide to Recanalization, Third Edition. Edited by Ron Waksman and Shigeru Saito.
© 2024 John Wiley & Sons Ltd. Published 2024 by John Wiley & Sons Ltd.
172
ever, retrograde approach may be considered as a
Ambiguousorbluntproximalcapofnativevessel
Equipmentavailability
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primary approach if there is proximal cap ambiguity, flush aorto-ostial lesion or difficult antegrade
catheter engagement (e.g., anomalous coronary),
bifurcation at the distal cap, or diffuse disease in
the distal vessel (Figure 19.1) [12]. Septal and SVG
are preferred over epicardial collaterals given lower
risk of complications, and vein grafts are often
favorable for crossing (even if occluded) due to
large lumen size, minimal tortuosity, and lack of
branch vessels [13].
Our general approach to retrograde venous CTO
intervention is as follows:
Imaging is key: Dual or triple access for complete
1
mapping angiogram. If the vein graft is occluded,
the vessel path may not be well-visualized. In this
case, surgical clips and coronary computed tomography may help delineate the vessel path with special attention paid to graft insertion site into the
native vessel. Reviewing old angiograms may also
be helpful.
2
Establish retrograde strategy: Two subgroups
of retrograde vein graft intervention are considered: occluded vein graft vs. patent vein graft:
patent vein grafts are approached similar to other
retrograde techniques (See Chapters 18 and 27).
Occluded vein graft (Figure 19.2) intervention
(focus of this section) presents unique challenges: (A) crossing the CTO; (B) crossing into
the target vessel; (C) Recanalization retrograde
into target vessel.
Cross vein graft CTO: We favor an initial
3
approach with guide extension, loaded support
catheter with the workhorse wire. Attempt CTO
crossing with the workhorse, then follow the preferred wire escalation protocol. If wire escalation
fails, electrified guidewire (discussed below),
laser atherectomy, or the Frontrunner device
(Cordis, Santa Clara, California, USA) may be
employed.
4 Advance guide extension: Once the CTO is crossed,
the guide extension is advanced with the balloonassisted tracking technique to the distal vein graft
(Figure 19.3).
Availableinterventionalcollateral
Longlesionlength
Veingraftstump(lackofaorto-ostialflush
occlusion)
FavorableSVG-nativearteryanastomosisangle
Bifurcationatdistalcap
Figure 19.1 Lesion characteristics that may favor retrograde
approach.
CHAPTER 19 Retrograde CTO Intervention via Vein Grafts 173
Figure 19.2 Angiogram: dual injection with vein graft
occlusion.
Figure 19.3 Balloon-assisted tracking to advance guide
extension to distal vein graft.
5 Crossing into the native vessel: The acute angle
into the native vessel may be approached in several ways: (1) making an “S” bend on the wire;
(2) using a double lumen catheter to direct the
wire; or (3) using an angulated microcatheter
(Figure 19.4).
6 Perform retrograde CTO-PCI: Advance retro-
grade through the CTO and perform PCI using
established retrograde techniques. If it is difficult to
advance equipment, the retrograde wire may be
externalized, establishing a rail to permit “flossing.”
Note: avoid pulling a flossed guidewire across a
174 PART IV Wires Technique
Figure 19.4 Acute angle of vein graft insertion site into
native vessel.
Figure 19.5 Hinge point at insertion site; avoid flossing
against hinge point without balloon or support catheter
protection.
hinge point without the protection of a support/
balloon catheter (Figure 19.5).
7 Perform final angiography (Figure 19.6). Consider
SVG coiling (see below).
SVG coil to limit restenosis caused by
competitive flow
After CTO-PCI of a grafted vessel, continued competitive flow from an open graft may contribute to
restenosis in the native vessel, a concept that is supported by studies showing increased restenosis in
areas of flow disturbance [14]. Thus, some operators
Figure 19.6 Final angiogram after retrograde intervention
of native right coronary artery via totally occluded vein
graft.
may opt to close the venous graft after successful
revascularization. Wilson et al. retrospectively
reviewed a series of 33 patients who underwent SVG
“sacrifice”; grafts were closed using an Amplatzer
Vascular Plug (AVP; Abbott Vascular) with a high
success rate (97.0%). Over a mean follow-up of
602± 393 days from the date of SVG closure, the
incidence of target lesion failure was 9.1% (n = 3)
without any other procedural complications.
However, this study did not have a comparator
group and it is unclear how many of these grafts
would have closed spontaneously [15].
Dautov et al. report on a subset of patients who
underwent retrograde SVG CTO PCI. Thirty-four
cases were reported: After experiencing poor outcomes in two cases where occlusive coils were not
placed (native stents occlusion and graft occlusion),
all subsequent cases had coiling if there was
Thrombolysis in Myocardial Infarction (TIMI) 2-3
flow through the graft at case end. As a result, 15/34
(44%) cases received coils without further occurrence
acute native vessel closure [1].
Electrosurgical recanalization of CTO
lesions
Retrograde CTO intervention via a vein graft may be
impeded by CTO of the vein graft itself. These lesions
may be particularly difficult to cross due to long-term
chronicity, fibrous cap, and poor guide support due to
ostial occlusion. After conventional CTO strategies
have been considered, utilizing electrosurgery, specifically, an 0.014” guidewire connected to a radiofrequency (RF) generator, is one more technique to
CHAPTER 19 Retrograde CTO Intervention via Vein Grafts 175
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traverse a fibrotic lesion. However, it is important to
recognize that RF energy cannot burn through confluent calcium.
Transcatheter electrosurgery has many applications including (1) perforation to traverse cardiac
chambers, (2) linear tissue laceration (e.g.,
LAMPOON or BASILICA), and (3) perforation to
recanalize occlusive lesions [16]. There are multiple
case reports utilizing RF to cross vascular occlusions in the peripheral vasculature [17, 18] and coronary arteries. This approach, dubbed “E-CART”
(Electrocautery-assisted Re-entry), has been
reported for aorto-ostial right coronary artery CTO
approached retrograde via left coronary collaterals
[19]. Electrosurgery may be similarly applied in an
occluded vein graft.
There are currently no commercially available
dedicated electrosurgery 0.014” guidewires. The
PlasmaWire (RetroVascular, Asahi Intecc, Nagoya,
Japan) has been shown to be effective in a small
case series but is not yet on the market [20]. In the
absence of dedicated devices, transcatheter electrosurgery can be performed using off-label equipment: a stiff coronary guidewire such as 0.014”
Astato XS 20 or amputated Confianza PRO 12
(Asahi Intecc, Nagoya, Japan), an insulating polymer jacket wire convertor (e.g., Piggyback, Teleflex,
Morrisville, NC) or other microcatheter, and an
electrosurgical pencil and hemostatic forceps to
connect to the back of the guidewire. This list of
0.014” guidewires is not exhaustive, but it is important to understand that not all guidewires work for
transcatheter electrosurgery. For example, polymer
jackets will insulate the wire, preventing the passage of current to the tissue. CTO wires with high
tip load are typically preferred, as they are less
likely to buckle, causing linear rather than punctate
cuts [16].
The guidewire should be brought in contact with
the target lesion and confirmed in multiple views.
The wire convertor/microcatheter is brought just
short of the wire tip to concentrate the RF energy
onto the tip rather than allowing dispersal of current
into the blood in contact with exposed wire. The
proximal end of the guidewire is connected to a unipolar electrosurgery pencil using forceps, and a dispersive electrode (“ground pad”) is placed on the
patient to complete the circuit. The guidewire is then
energized by activating the electrosurgical pencil in
“pure cut” mode at 30–50W for a 1-sec burst; cutting mode delivers continuous-duty RF energy that
vaporizes tissue. “Coagulation” or “blend” modes
should not be used, as they deliver pulsed energy to
generate heat for blood coagulation, which is not
helpful [16].
Summary
Retrograde CTO intervention via vein grafts has been
shown to be safe and feasible in many cases.
Comprehensive understanding of relevant anatomy,
proper preparation and meticulous technique are
needed to achieve high success rates.
References
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20
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CHAPTER 20
Tips and Tricks of the CART and
Reverse CART Technique
Arber Kodra2,*, Chad Kliger
Tak Kwan
1
Lenox Hill Hospital/Northwell Health, Hofstra School of Medicine, New York, NY, USA
2
Department of Cardiology, Lenox Hill Hospital, New York, NY, USA
* Corresponding authors
Chronic total occlusion (CTO) remains one of the most
challenging complexities in percutaneous coronary
interventions. Retrograde recanalization complements
the classical antegrade approach and has been associated with a high degree of success even in the most
complex cases [1]. The controlled antegrade and retrograde subintimal tracking (CART) technique and its
modified version “the reverse CART” technique, are
two methods that utilize retrograde recanalization [2].
To understand how the CART procedure works,
it is important to first understand the anatomy and
histopathology of a CTO. Chronic coronary occlusions often arise from thrombus formation following
repeated plaque rupture in diseased vessels, leading to
eventual obliteration of the lumen [3]. The thrombus,
along with the lipid-rich cholesterol esters from the
fractured plaque, is gradually replaced with collagen
and calcium [4, 5]. Calcified, collagen-rich fibrous
tissue forms at the proximal and distal ends of a CTO
providing a barrier of entry into a softer core of organized thrombus and lipids [5]. With time, the edges
of the occluded plaque become progressively more
fibrous and calcified [6]. It is this hard, fibrous, cap
that makes crossing with conventional guidewires difficult and successful recanalization a challenge.
Current device strategies to cross CTOs include
tapered guidewires that engage luminal microchannels
and ablative and mechanical devices designed to dissect through the hard, fibrous cap. Historically, the
technical success rate has been limited to 65–70% with
the antegrade approach [7]. As knowledge and expertise of percutaneous coronary intervention (PCI) has
developed, the retrograde approach has improved the
success rate of complex CTO PCI when the conven-
2
& Michael Kim
1,2,
*, Apurva Patel2, Craig Basman2,
2
tional antegrade approach is ineffective, unsafe, or
inefficient. Angiographic markers of potential procedural failure with the antegrade approach include the
morphologic absence of a tapered tip, presence of a
bifurcation at the distal cap, long diffusely diseased
distal vessel, anomalous coronary arteries, vessel tortuosity greater than 45°, and flush aorto-ostial occlusions
[8]. The advent of the CART and reverse CART techniques has allowed operators to treat even these challenging CTOs. Despite this, adoption of these
techniques is still limited to ~14–24% of CTO PCI [9].
The CART technique consists of antegrade wiring through the CTO after a retrograde balloon has
created a local subintimal dissection to facilitate wire
crossing to the distal true lumen (Figure 20.1) [1].
Once the antegrade wire is placed into the subintima,
the retrograde wire is navigated across the distal true
lumen towards the CTO through a vessel with the
aid of a microcatheter to protect the vessel. A double
bend on the wire or a microcatheter with an angled tip
may be required for entering septal collaterals. Various
guidewires can be used to cross collaterals including
the XT-R, Sion, Sion Black, and Suoh 03 (Asahi Intecc,
Nagoya, Japan). A 1-mm bend is usually made on the
guidewire tip. Balloon anchoring may be necessary to
facilitate wire maneuverability especially though acute
bends along the collateral vessel. Once the retrograde
wire is advanced into the subintimal space at the CTO
site, the subintimal space is enlarged by inflating a
balloon (2.0–2.5 mm) inserted over the retrograde
wire. While the balloon is being deflated, the antegrade
wire is advanced further along the deflated retrograde
balloon and into the distal true lumen. Angioplasty and
stenting are performed in an antegrade manner. The
Chronic Total Occlusions: A Guide to Recanalization, Third Edition. Edited by Ron Waksman and Shigeru Saito.
© 2024 John Wiley & Sons Ltd. Published 2024 by John Wiley & Sons Ltd.
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