Tips and Tricks of the CART and Reverse CART Technique

Chronic total occlusion (CTO) remains one of the most challenging complexities in percutaneous coronary interventions. The controlled antegrade and retrograde subintimal tracking (CART) technique and its modified version “the reverse CART” technique, are two methods that utilize retrograde recanalization. The advent of the CART and reverse CART techniques has allowed operators to treat even these challenging CTOs. One adaptation of the CART technique involves the use of intravascular ultrasound (IVUS). IVUS is useful to estimate the precise size of antegrade balloon that can lead to medial disruption. Technical and procedural success rates of CTO PCI have risen tremendously over few years, because of operator experience, improved equipment, and refinements of retrograde approaches such as the CART and reverse CART techniques. Further technical improvements are necessary to simplify the techniques making them more widely used.

References

Surmely JF , Tsuchikane E , Katoh O et al . New concept for CTO recanalization using controlled antegrade and retrograde subintimal tracking: the CART technique . J Invasive Cardiol 2006 ; 18 : 334 – 338 .
PubMed Google Scholar
Matsuno S , Tsuchikane E , Harding SA , Wu EB , Kao HL , Brilakis ES , Mashayekhi K , Werner GS . Overview and proposed terminology for the reverse controlled antegrade and retrograde tracking (reverse CART) techniques . EuroIntervention 2018 ; 14 : 94 – 101 .
10.4244/EIJ-D-17-00867
PubMed Web of Science® Google Scholar
Kandzari DE . The challenges of chronic total coronary occlusions: an old problem in a new perspective . J Intervent Cardiol 2004 ; 17 : 259 – 267 .
10.1111/j.1540-8183.2004.04029.x
PubMed Google Scholar
Srivatsa S , Edwards WD , Boos CM et al . Histologic correlates of angiographic chronic total coronary artery occlusions: influence of occlusion duration on neovascular channel patterns and intimal plaque composition . J Am Coll Cardiol 1997 ; 29 : 955 – 963 .
10.1016/S0735-1097(97)00035-1
CAS PubMed Web of Science® Google Scholar
Stone GW , Kandzari DE , Mehran R et al . Percutaneous recanalization of chronically occluded coronary arteries: a consensus document: part I . Circulation 2005 ; 112 : 2364 – 2372 .
10.1161/CIRCULATIONAHA.104.481283
PubMed Web of Science® Google Scholar
Suzuki T , Hosokawa H , Yokoya K et al . Time-dependent morphologic characteristics in angiographic chronic total coronary occlusions . Am J Cardiol 2001 ; 88 : 167 – 169 .
10.1016/S0002-9149(01)01614-9
CAS PubMed Web of Science® Google Scholar
Khan MF , Wendel CS , Thai HM , Movahed MR . Effects of percutaneous revascularization of chronic total occlusions on clinical outcomes: a meta-analysis comparing successful versus failed percutaneous intervention for chronic total occlusion . Catheter Cardiovasc Interv 2013 ; 82 : 95 – 107 .
10.1002/ccd.24863
PubMed Web of Science® Google Scholar
Wu EB , Tsuchikane E , Ge L , Harding SA , Lo S , Lim ST , Chen JY , Lee SW , Qian J , Kao HL et al . Retrograde versus antegrade approach for coronary chronic total occlusion in an algorithm-driven contemporary Asia pacific multicenter registry: comparison of outcomes . Heart Lung Circ 2019 ; 29 : ( 6 ) 894-903 pii:S1443-9506(19)31329-0.
PubMed Web of Science® Google Scholar
Hoye A , van Domburg RT , Sonnenschein K , Serruys PW . Percutaneous coronary intervention for chronic total occlusions: the Thoraxcenter experience 1992-2002 . Eur Heart J 2005 ; 26 : 2630 – 2636 .
10.1093/eurheartj/ehi498
PubMed Web of Science® Google Scholar
Surmely JF , Katoh O , Tsuchikane E et al . Coronary septal collaterals as an access for the retrograde approach in the percutaneous treatment of coronary chronic total occlusions . Catheter Cardiovasc Interv 2007 ; 69 : 826 – 832 .
10.1002/ccd.20816
PubMed Web of Science® Google Scholar
Wu EB , Tsuchikane E , Lo S , Lim S , Ge L , Chen J . Retrograde algorithm for chronic total occlusion from the Asia Pacific Chronic Total Occlusion club . Asian Interv 2018 ; 4 : 98 – 107 .
Google Scholar
Dash D . Guidewire crossing techniques in coronary chronic total occlusion intervention: A to Z . Indian Heart J 2017 ; 68 : 410 – 420 .
10.1016/j.ihj.2016.02.019
Google Scholar
Huang Z , Zhang B , Chai W , Ma D , Liao H , Zhong Z , Wang F , Lin J . Usefulness and safety of a novel modification of the retrograde approach for the long tortuous chronic total occlusion of coronary arteries . Int Heart J 2017 ; 58 : 351 – 356 .
10.1536/ihj.16-337
PubMed Web of Science® Google Scholar
Dash D . Iteration of reverse controlled antegrade and retrograde tracking for coronary chronic total occlusion intervention: a current appraisal . Kor Circ J 2020 ; 50 : 867 – 879 .
10.4070/kcj.2020.0156
CAS PubMed Web of Science® Google Scholar
Ito S , Suzuki T , Ito T . Novel technique using intravascular ultrasound-guided guidewire cross in coronary intervention for uncrossable chronic total occlusions . Circ J 2004 ; 68 : 1088 – 1092 .
10.1253/circj.68.1088
PubMed Web of Science® Google Scholar
Grantham JA . The final steps of the retrograde technique: wire externalization, stenting, and wire removal . Interv Cardiol Clin 2012 ; 1 ( 03 ): 345 – 348 .
PubMed Google Scholar

Chronic Total Occlusions: A Guide to Recanalization, Third Edition