Solutions for Complex Reverse CART: IVL and Subintimal Calcium Modification

What do you do when a calcified RCA CTO case stalls, your equipment will not deliver, and conventional reverse CART strategy becomes difficult?

In this MurmurMD discussion, Dr. Chris Brown and Dr. Eric Rothstein review a challenging CTO case involving a 57-year-old patient with five years of angina, a large ischemic RCA territory, prior LAD treatment without symptom improvement, and a heavily calcified RCA CTO.

The case evolves through several classic CTO decision points: upfront ADR consideration, side-branch anchoring, architectural knuckle formation, intralesional ambiguity, retrograde septal crossing, difficulty joining tissue planes, and ultimately the use of intravascular lithotripsy to modify calcified subintimal/extraplaque space and facilitate reverse CART.

KEY TOPICS

• RCA CTO with long-standing angina and ischemia

• Hybrid CTO strategy and switching approaches mid-case

• Side-branch anchor technique for guide support

• Large architectural knuckle vs small knuckle strategy

• Intralesional ambiguity and how to define the vessel course

• Retrograde septal crossing strategy

• Why guide extension delivery can fail in calcified CTOs

• IVL use in the subintimal/extraplaque space

• Shockwave to facilitate reverse CART

• Trapping, microcatheter delivery, and externalization

• IVUS interpretation after CTO crossing

• Conservative sizing in the subintimal space

• Why IVL may be preferable to atherectomy in this setting

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Chapters:

00:00 – Key concept: microcatheter delivery and externalization

00:22 – Case introduction

00:44 – Patient presentation: 57-year-old with five years of angina

01:45 – RCA CTO anatomy, J-CTO score, and initial strategy

02:46 – Failed knuckle formation and need for more guide support

03:28 – Side-branch anchor technique in the conus

04:44 – Large architectural knuckle strategy

05:54 – Intralesional ambiguity and CTO decision-making

06:54 – Options: bigger knuckle, BASE, Carlino, or retrograde definition

07:55 – Switching to retrograde strategy

08:57 – Septal surfing and retrograde crossing

11:00 – Retrograde support, guide extension limits, and plaque modification

12:16 – Balloons fail to expand in the subintimal space

14:00 – Shockwave IVL to modify calcified CTO architecture

15:00 – Anchor technique to deliver larger equipment

15:39 – Retrograde wire choice for reverse CART

17:07 – Moving the reverse CART strategy proximally

19:01 – Wiring the guide vs snaring

19:50 – Balloon trapping to deliver the microcatheter

20:50 – Externalization with R350 or RG3

21:13 – IVUS: true lumen, subintimal space, and hematoma

22:10 – Ballooning, stent sizing, and conservative expansion

22:49 – Final IVUS and result

23:27 – Why IVL may be safer than atherectomy in the extraplaque space

24:23 – Closing thoughts and key learning points

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