Bite in:a novel technique for retrograde chronic total occlusion revascularization

Abstract The "tip-in" technique serves as an alternative externalization method when the retrograde microcatheter (MC) advancement to the antegrade guiding catheter proves unattainable. The conventional tip-in technique involves using the retrograde guidewire (RGW) to cross the chronic total occlusion (CTO) body, allowing it to be tipped into the MC and advanced through the antegrade guiding catheter. However, this technique can sometimes be challenging because of the low control of RGW manipulation or RGW deformation.Therefore, we have developed a novel strategy termed "bite in" to overcome this issue. In this refined approach: the RGW is first advanced to the Guidezilla followed by controlled antegrade MC rotation to achieve spontaneous RGW capture at the coaxial interface (Figure1),eliminating the need for active RGW manipulation during this critical phase. Methodological validation was performed in 20 cases extracted from our Chronic Total Occlusion databases. Baseline characteristics demonstrated complex lesion profiles with mean J-CTO、PROGRESS-CTO, and JR-CTO score were 3±1,1±0.7 and 2±0.7 respectively. The Primary retrograde approach was 20%(4/20).Use of nonseptal collateral channel was 20%(4/20).The procedural metrics mean radiation dose was 1280±720mGy.The technique and procedural success were 100%.No in-hospital major adverse cardiac events were found. Bite-in is a feasible and safe technique that facilitates retrograde wire externalization. A 65-year-old man presented with Canadian Cardiovascular Society class III angina despite maximal medical therapy; he was referred for chronic total occlusion percutaneous coronary intervention. Initially, we selected the active greeting technique after a successful etrograde approach. However, this strategy failed (Figures 2C and 2D). Instead of traditional approaches to increase the support of the retrograde system, we choose the "bite-in" strategy. The operation skills are as follows: the Gaia Third RGW (AsahiIntecc) was advanced to the first bend of the right coronary artery at the outer curve of Guidezilla. Then, the operator navigated the antegrade Corsair 135 (Asahi Intecc) (white thin arrow in Figure 2E) to advance by rotating moderately. At this juncture, because of shear physics, the antegrade MC captured the RGW without RGW manipulation at the same point on the outer curvature (Figures 2E and 2F). Percutaneous coronary intervention was then performed after intravascular ultrasound confirmation ( Figures 2G and 2H). The patient was angina free at the 3-month follow-up. These cases introduce the "bite-in" method to address the limitations of the Finecross catheter’s (Terumo) tip-in method, which often exhibits adequate crossing ability and support. We have detailed the application scenarios for various retrograde approaches, including our novel "bite-in" technique, thereby enhancing the existing chronic total occlusion guidelines and the consensus document.

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