A novel technique, “power Carlino,” was found to be useful for crossing wire-impenetrable proximal caps during chronic total occlusion (CTO) revascularization. This new method was presented at the Transcatheter Cardiovascular Therapeutics (TCT) conference, held November 4 to 6, 2021, and was published in JACC: Cardiovascular Interventions.

Details of the technique were authored by researchers from Henry Ford Hospital and Minneapolis Heart Institute at Abbott Northwestern Hospital in the United States.

A woman aged 78 years was referred for percutaneous intervention of the right coronary artery. The artery presented with CTO due to medically refractory angina. The occlusion was long and had a Multicenter CTO Registry in Japan score of 3.

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The investigators attempted to puncture the proximal cap using highly penetrating guidewires but failed. They next attempted “scratch and go” and “knuckle wire” techniques after switching to antegrade dissection, but they had no success.

Next, the investigators performed the Carlino technique using 0.5 mL contrast. They injected the contrast through a microcatheter as far distally in the proximal cap as possible. This attempt was also not successful, and the dissection partly extended to the proximal vessel.

They next left the knuckle and rewired the workhorse wire to deliver the microcatheter to the proximal cap, inflating a 3.0 mm balloon over the knuckle wire and injecting an additional 0.5 mL contrast through the microcatheter.

This technique ¾ the power Carlino ¾ was successful at knuckling a Gladius wire into the marginal branch. They finally used a controlled reentry approach with a Stingray balloon into the distal right coronary artery and observed a satisfactory final angiographic result.

In summary, the power Carlino technique comprises the injection of contrast through a microcatheter, which is advanced as far as possible against the proximal cap while being anchored against the vessel wall by an inflated balloon (1:1 in size) with the target vessel lumen.

The technique authors cautioned that there is an increased risk for perforation, so only a small amount of contrast should be injected, and constant fluoroscopic guidance is needed.

Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of disclosures.


Megaly M, Basir MB, Brilakis E, Alaswad K. “Power Carlino” A novel method for modifying wire-impenetrable proximal caps during chronic total occlusion revascularization. J Am Coll Cardiol Intv. Published online November 4, 2021. doi:10.1016/j.jcin.2021.08.065