Intracoronary snaring of the retrograde guidewire: A novel method to solve compartment mismatch in complex retrograde CTO PCI

The retrograde approach has allowed a remarkable improvement in the success rate of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). After collateral channel crossing, the most crucial aspect of retrograde CTO PCI is creating the connection between the antegrade and retrograde system. Currently, the most common technique to achieve this is reverse controlled antegrade and retrograde subintimal tracking. However, this maneuver sometimes fails due to compartment mismatch (intraplaque situation of one wire and extraplaque situation of the other). New approaches are therefore needed to overcome challenges in this important step of the procedure. Here we present an innovative solution to this problem, which involved capturing the retrograde guidewire (advanced into a side branch at the distal cap) with a microsnare that had been advanced antegradely: this severed the dissection flap separating the antegrade and retrograde system, thus allowing us to successfully recanalize the CTO.