1) Retrograde PCI requires specific wire maneuvers to be mastered, including septal channel surfing, straight wire fast drilling, controlled drilling with sharp wires, and using knuckled wires. 2) These techniques allow for retrograde crossing of collateral channels, occluded grafts, and CTO lesions. 3) With practice of these simple maneuvers, retrograde PCI can be performed safely and effectively.

1. Wire maneuvers in
retrograde PCI
Stéphane Rinfret, MD, SM
Quebec Heart and Lung Institute
Quebec City, Quebec, Canada
Session 3 “AN INITIATION TO RETROGRADE TECHNIQUES”

2. Conflict of interest
• None specific to that presentation

3. Specific wire maneuvers
in retrograde CTO PCI
• Retrograde channel crossing
• Occluded SVG crossing
• Retrograde CTO ‘travelling’
• Retrograde CTO crossing

4. J Am Coll Cardiol Intv 2012;5:1–11

5. Pathways to the distal cap
• Collateral channels (CC)
– Septal CC
– Epicarcial CC
• SVGs
– Patent: easiest cases
– Occluded: can be crossed if the occlusion is
younger than 1 year and the proximal cap is
not blunt, to deliver retrograde gear

6. Principles with
collateral channels (CC)
1. Septal CCs
– Safer than epicardial CCs: always try first
– Straight is better, tortuosity is more an issue
– We CAN wire invisible CCs
2. Epicardial CCs
– Larger size is important
– Tortuosity less an issue
– Lower threshold post CABG : unlikely
tamponnade in case of CC perforation
– Danger is no prior CABG, small and tortuous

7. 2 schools for
wiring collaterals
• Japanese school
– Distal selective tip injection to locate and isolate
a collateral channel
– Advantage: help plan your wire maneuvers
– Risk: Busting the collateral with injection
• Western school
– Surfing, by feeling of the wire, searching for the
path of least resistance
– Advantage: test more options
– Risk: Crossing a collateral that is too small to
allow for the Corsair to cross

8. Werner Classification
A CC0=no visible connection between donor and recipient artery
B. CC1=continuous, thread-like connection
C. CC2=small side branch-like size of the channel
Rathore et al. Circ Cardiovasc Intervent. 2009; 2:124-132
Werner GS et al, Circulation. 2003;107(15):1972-7.

9. Predictors of
retrograde failure
CC0=
Rathore et al, Circ Cardiovasc Intervent. 2009;2:124-132
Or CC0

10. Successfully crossed septal CC
according to Werner Class (n=79)
n=27 n=41 n=11
P=0.714
%
78 76
82
0
10
20
30
40
50
60
70
80
90
100
CC0 CC1 CC2
Success with surfing technique
Success
Rinfret S et al, EuroPCR 2013

11. Septal “surfing” technique
• Involves placing
1. workhorse wire in proximal CC
2. microcatheter (Corsair or FineCross),
3. “surf” with a Sion or Fielder FC for low
resistance connection (no wedged tip injection)
• Help crossing even invisible CCs
– Advance wire while keeping wire tip free
– Drilling and quick sliding when wire seems to follow a
vascular structure
– Try to replicate the same wire bends up to certain point:
indicate you are in a vessel up to that point

12. Ostial and blunt RCA CTO with calcium
J-CTO=3 (previous failure)
Rencontres francophones de CTO, Strasbourg, December 2013

13. Ostial and blunt RCA CTO with calcium
J-CTO=3 (previous failure)
Case performed with Nicolas Lhoest in Strasbourg, December 2013

14. The Hybrid Algorithm for
CTO PCI
Dual Catheter Angiography
1. Clear proximal cap
2. Good Distal Target
4. Length < 20mm
Antegrade Retrograde
yes no
Wire
escalation
Dissection Reentry
(crossboss-stingray)
Wire
escalation
Dissection Reentry
(reverse CART)
yes yes nono
Brilakis E, Grantham JA, Rinfret S, et al. J Am Coll Cardiol Intv 2012
3. Interventional collateralno

15. The Hybrid Algorithm for
CTO PCI
Dual Catheter Angiography
1. Clear proximal cap
2. Good Distal Target
4. Length < 20mm
Antegrade Retrograde
yes no
Wire
escalation
Dissection Reentry
(crossboss-stingray)
Wire
escalation
Dissection Reentry
(reverse CART)
yes yes nono
Brilakis E, Grantham JA, Rinfret S, et al. J Am Coll Cardiol Intv 2012
3. Interventional collateralno

16. Primary retrograde-In S1

17. Septal surfing with Sion wire

18. Connection though CC0

19. Replay: wire tracks a vessel

20. Advancing Corsair to distal
cap
Alternating clockwise and counter clockwise rotations

21. Retrograde true-to-true crossing
with Pilot 200 (in the aorta)
Drilling with torqueing device if wire is tight

22. Final result after snaring, stenting and
removal of retrograde system (time=1h15
min)

23. Favorable for antegrade?
Dual radial
8F sheathless anteg
6F retro

24. Nice septal CCs, some CC0,
some CC1 and some CC2
1
2
0

25. Failed cap puncture

26. Switch to retrograde in CC2
Tip injection after failed
surfing

27. LAO tip injection
to understand mode of failure

28. More than 180⁰ loop

29. Attempt to cross

30. Failure from perforation

31. Switch to big S1, connecting?
?

32. Surfing over 10 small septal
CC: Stochastic event

33. Reverse CART

34. Final

35. Epicardial CC wiring
• Only Sion -no other wire
• Adding a second tiny bend more proximal
often helps
• Keep wire free and moving
• Follow the path of least resistance

36. Dual injection revealing huge
proximal ambiguity

37. Nice epicardial collaterals

38. Crossing epicardial CC from
RIMA-RCA with Sion wire

39. Corsair advanced easily to
ostium-
Pilot 200 crossed retrograde

40. Final result post DES

41. 1 yr after RCA CTO PCI
with ADR-now LCX CTO
CC
CTO

42. Very nice healing of
> 100mm SI DES

43. Sion and Corsair

44. Sion and Corsair

45. Sion and Corsair

46. Sion and
knuckled Fielder XT

47. Retrograde knuckle to cap
Ping pong
technique

48. Antegrade knuckle

49. Dissection

50. Re-entry

51. Stenting on externalized wire

52. Final

53. Using old occluded SVGs

54. Patent LIMA, Occluded SVG
LM and LCx CTO
Tortuous Epicardial
CC2

55. Kissing wire technique
with LIMA

56. CP 12 in diagonal branch

57. Wire exchanged

58. Switch guide to SVG: retro through
occluded segment (with previous stents)
with Corsair and Pilot 200

59. Distal contrast injection
through the Corsair in the SVG

60. Retrograde Pilot 200
wire to LCX

61. Exchanged for FineCross, and
Pilot 200 to antegrade guide

62. Exchanged for FineCross,
and wire to antegrade guide

63. Stenting after externalization

64. After removal of retrograde
equipment

65. Final after T-stenting of LM-LCx,
and stenting LAD-D1

66. Retrograde wire manoeuvers
to cross
• Straight Pilot 200 and fast drilling for short
lesions
• Straight Confianza Pro 12 if no ambiguity,
and controlled drilling for re-entry or
crossing
• Knuckled wires (Fielder XT or Pilot 200)
for travelling into the CTO segment
– Stay into vascular structure, less likely to
perforate

67. LAD CTO with
interventional septal CC
X

68. Proximal cap ambiguity and
non-interventional epic CC

69. Retrograde approach
Always attempt septal first

70. Sion Wire

71. Straight Pilot 200 out of
coronary path

72. Corsair at distal cap

73. Retrograde dissection with
knuckled wire

74. Re-entry at the carina level
with Pilot 200

75. Final result

76. Proximal RCA cap ambiguity

77. Proximal RCA cap ambiguity
Many bridge
Collateral channels

78. Few septal CCs

79. Connection through
invisible CC0 channel

80. Retrograde dissection with
knuckled wire (XT)

81. Retrograde dissection

82. No more ambiguity:
Reverse CART

83. Connection into
antegrade guide

84. Final

85. Conclusion
• Specific manoeuvers need to be
mastered for effective retrograde PCI
– Septal surfing
– Straight wire fast drilling
– Straight wire controlled drill with sharp wire
– Knuckled wire
• Simple, easy to learn, no magic
• Go ahead and try safely!
stephane.rinfret@criucpq.ulaval.ca