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 🔔 Subscribe for more insights from interventional experts and real-world program builders. 📱 Download the app: https://apps.apple.com/app/apple-store/id1586692687 📺 Follow us on YouTube: https://www.youtube.com/channel/UCfrLYhAhliQ2ZvXinkDCZvA 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 #CTO #ComplexPCI #IVL #IntravascularLithotripsy #ShockwaveIVL #ReverseCART #RCACTO #CoronaryCalcium #InterventionalCardiology #CathLab #MurmurMD