A 73-year-old man with prior bypass surgery in 2016 consisting of a left internal mammary graft to the left anterior descending artery and a saphenous vein graft to the right coronary artery, diagonal 1, and obstuse marginal presented with stable limiting angina. He has unstable angina pectoris history in July 2023 and is being treated for hypertension, dyslipidemia, and type II diabetes. At presentation, his physical examination including cardiovascular examination was unremarkable.

In July 2023, Computed Tomography Angiography showed failed graft saphenous vein graft to right coronary artery. At presentation, electrocardiography showed sinus rhythm with inverted T wave at V5, V6. Echocardiography showed ejection fraction 49% and chamber dilatation (left atrium and ventricle). Regional wall motion abnormalities was seen in inferior and inferoseptal segment. His chest x-ray and blood test laboratories finding were within normal range.

In August 2023, the patient underwent coronary angiography for unstable angina pectoris, which showed failed graft saphenous vein graft to posterior descending artery,  and chronic total occlusions of right coronary artery, left anterior descending artery, and left circumflex artery.

Right femoral 45 cm long sheath 7 Fr and right radial 6 Fr conventional sheath was used for vascular access. AL 0.75 side hole 7 Fr and XB 3.5 6 Fr guiding catheters through right femoral and right radial access were used to engage Right Coronary Artery and Left Coronary Artery, respectively. An antegrade approach with guidance of retrograde wire was chosen as strategy. Therefore, after identifying a septal collateral emerging from the proximal Left Anterior Descending, collateral navigation with Suoh 03 backed up Corsair Pro XS 155 cm Microcahteter (MC) was successfully performed. Further antegrade attempt using Miracle 3 and Gladius EX 14 wire with Corsair Pro 135 cm MC was unsuccessful. Subsequently, a retrograde approach with reverse controlled antegrade and retrograde subintimal tracking (CART) was chosen as secondary strategy. Attempt of connecting antegrade and retrograde channel with balloon inflation (1,5 mm and 2.0 mm semi compliant (SC) balloons) over the antegrade wire was performed but failed. A guide catheter extension (Guideliner 6F) is advanced over the antegrade guidewire followed by balloon dilatation (2.5 mm and 3.0 mm SC balloons). After predilatation with balloons, we were able to advance the Retrograde (RG 3) wire and MC beyond the distal cap of the occlusion into the guidecatheter extension. Retrograde wire was externalized and used for subsequent angioplasty with 3.0 mm Non Compliant balloon. Drug Eluting Stents 2.5/30 mm and 3.0/38 mm was implanted with an excellent result.

The reverse controlled antegrade and retrograde subintimal tracking (CART) is the most commonly used technique for retrograde chronic total occlusion percutaneous coronary intervention. Guide extension can be particularly useful if reverse CART is challenging to complete.