The retrograde coronary approach for chronic total occlusions: mid-term results and technical tips & tricks

Coronary chronic total occlusions (CTO) remain a challenging lesion subset for interventional cardiologists. The retrograde approach is a novel but still incompletely described technique. We report our 5-year-long experience in retrograde percutaneous coronary intervention (PCI) for CTOs.

We abstracted patient and procedural data on all cases with attempted retrograde approach by means of a native septal or epicardial collateral pathway. End-points were wiring, angiographic and procedural success, plus long-term major adverse cardiovascular events (MACE).

The retrograde approach was used in 18 patients, including 11 CTOs of right coronary artery (RCA), 3 of left circumflex (LCX), and 4 of left anterior descending (LAD), with procedural success in 12 (67%). Conversely, two cases of wiring failures, three angiographic failures despite successful retrograde wiring, and one postprocedural myocardial infarction in an otherwise angiographically successful procedure were found. Causes of wiring failure were inability to retrogradely cross the distal (1) or the proximal stump (1) with the wire, while angiographic failures were due to interruption of the procedure due to rupture of a minor septal collateral branch during attempts at advancing the noninflated balloon (1) or persistent inability to deliver the balloon through the chosen collateral (2). Follow-up at a mean of 15 months showed MACE had occurred in five (28%) subjects.

The retrograde approach appears feasible and safe in the percutaneous management of coronary occlusions, and its application can be envisioned as a promising alternative in selected patients in whom antegrade approaches fail or are unsafe.