A woman with a non-ST elevation myocardial infarction after orthopedic surgery underwent a coronary angiogram showing a CTO of the dominant Left Circumflex (LCx) artery in its distal segment, just after a large marginal branch, and a severe lesion of the mid Left anterior descending (LAD) artery. The proximal cap of the CTO was ambiguous (blunt stump), meanwhile significant retrograde septal collaterals to the distal LCx were noticed from the LAD (Fig. 19.1a). The heart-team decided to aim at complete revascularization, in first instance via a percutaneous approach. A direct retrograde approach to tackle the LCx CTO was attempted. A Sion Blue wire supported by a 150 cm Corsair microcatheter was passed through the septal channels into the distal LCx. The occlusion was then passed with a Pilot 200 wire. The Corsair microcatheter was then advanced up to the guiding catheter, making a loop out of it (Fig. 19.1b). Then a 330 cm RG3 wire was externalized. The Corsair microcatheter was then removed and the procedure was successfully completed via the antegrade route on the RG3 wire, with implantation of two overlapping drug eluting stents (Fig. 19.1c). The patient was subsequently treated also in the LAD with success.

A man with history of previous anterior myocardial infarction presented with angina pectoris and anteroseptal inducible ischemia around the old infarcted area. The coronary angiogram showed single vessel disease with CTO in the mid-LAD and retrograde epicardial collaterals from a large obtuse marginal (OM) artery. There was a clear proximal stump at the level of the CTO (Fig. 19.2a). Antegrade approach was attempted with a Sion Blue wire and microcatheter support. However, the wire went into a diagonal artery and the distal part of the CTO was not crossed. A retrograde approach was directly attempted. A Pilot 200 wire successfully passed via the OM and the epicardial collaterals to the apical LAD and a 150 cm Corsair microcatheter was advanced through this way. The LAD CTO was successfully passed using a Miracle 12 wire. Then the Corsair microcatheter was advanced up to the left main. It was then possible to externalize a 330 cm RG3 wire (Fig. 19.2b). In order to exchange the RG3 wire for a normal antegrade wire, two FineCross microcatheters inserted from both ends of the RG3 wire were used, and the microcatheter tips “kissed” at the distal part of the target vessel. It was possible to remove the RG3 wire via the retrograde collaterals, protected by the retrograde FineCross microcatheter, and the antegrade channel was preserved by the antegrade FineCross microcatheter. An Extra-support wire was inserted via the antegrade microcatheter and the LAD was successfully treated with four overlapping drug eluting stents (Fig. 19.2c).