Fig. 3

The Reverse Controlled Antegrade Retrograde Subintimal Tracking (CART) Technique. a Right coronary artery (RCA) with shepherd’s crook morphology occluded proximally; severely calcified chronic total occlusion (CTO) with blunt stump. b Contralateral injection revealing retrograde filling of the distal vessel via septal and epicardial collaterals. c After failure to cross the septal collaterals, switch to epicardial connections. Selective contrast injection through a Corsair microcatheter (Asahi Intecc, Japan) better delineates the course of the epicardial collaterals from the Left Circumflex Coronary (LCX) artery. d, e A tortuous continuous epicardial collateral (Werner CC2) is selected and crossed with a Fielder FC wire (Asahi Intecc, Japan). f Corsair microcatheter advanced into the distal true lumen over the Fielder FC wire; selective contrast tip injection confirms intraluminal position. g Retrograde wiring of the occlusion with a Gaia second wire (Asahi Intecc, Japan) and an Ultimate wire (Asahi Intecc, Japan); vessel course ambiguity. h Bilateral wiring of the occlusion with a Gaia second wire antegradely and an Ultimate wire (Asahi Intecc, Japan) retrogradely. i Retrograde wire knuckle in the subintimal space. j Antegrade balloon dilatations enlarging the subintimal space to facilitate retrograde wire crossing (reverse CART technique). k Retrograde wire (Ultimate) crosses the lesion and enters the ascending aorta; the Corsair is advanced through the body of the occlusion but the wire cannot be advanced in the antegrade guiding catheter. l Snaring of the retrograde wire into the antegrade guiding catheter. m Advancement of the Corsair into the antegrade guiding catheter. n Externalization of an RG3 wire (Asahi Intecc, Japan) allows antegrade insertion of balloons and stents. o Final angiographic result after implantation of 3.5 × 18 mm, 3.0 × 33 mm and 2.75 × 38 mm everolimus eluting stents. p Contralateral injection revealing intact collateral circulation. o Bilateral Injection confirming (Thrombolysis In Myocardial Infarction) TIMI III flow and no residual stenosis in the RCA