The Use of Crusade in the Retrograde Treatment

  • One of a common challenges in RCA CTO is that the distal cap ends at the junction of PDA and distal RCA
  • That means that if the retrograde approach is via the septal to PDA, the wire has to make a left turn to enter distal RCA
  • The challenge in this is that the entrance to distal RCA is not at all apparent and that the wire will naturally be deflect to the right side down Postero-lateral branch

This angiogram shows the distal RCA CTO
Collaterals are derived from LAD septal and a tortuous LCX epicardial

This AP cranial vies shows the distal cap is at the PDA/RCA junction
The distal cap is smooth and concaved towards RPL

Septal cross to PDA was not difficult

However, with repeated attempts with various wires, none would make the left turn from PDA into RCA
The ante-grade wire could not re-enter true lumen from the sub-intimal space either

With repeated attempts from both directions, false lumens were created

  • Since the wire is not able to go into RCA, a change of tactic was required
  • Although the LCx to RPL collateral was very tortuous, a Runthrough was able to be crossed into the RPL

  • With skillful maneuvering, the Rungthrough crossed the collateral and ended in the PDAL

Runthrough can be seen to enter PDA

  • Due to the fact that the CTO distal cap is concaved towards the RPL, wire naturally turns into PDA

Even with Ultimate Bro 3 and then Conquest Pro 12 (Confienza) the entrance to RCA could not be caught

  • Runthrough has now been placed in PDA
  • A Crusade is run down the LCx collateral on the Runthrough

  • With Crusade supporting the Ultimate Bro 3, the entrance of RCA could be caught

  • The swing angio shows that the retrograde wire has crossed the ante-grade wire

  • After reversed CART and externalisation, the rest of the procedure can be carried out as usual


  • Usually the collateral channels are too small to admit a Crusade
  • Fortunately in this case the collateral was large enough for a Crusade to go through
  • With the Crusade in position, the side hole of the Crusade offered enough support for the Conquest Pro 12 to enter the distal RCA