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Primary vs Secondary Retrograde Approach in Chronic Total Occlusion Percutaneous Coronary Interventions
Spyridon Kostantinis, Khaldoon Alaswad, Dimitri Karmpaliotis
1Center for Complex Coronary Interventions, Minneapolis Heart Institute, 920 E. 28th Street #300, Minneapolis, MN 55407 USA. esbrilakis@gmail.com.
Insights
Using the retrograde approach as the initial strategy for coronary chronic total occlusions (CTOs) percutaneous coronary intervention (PCI) improves success rates. This primary retrograde approach shows higher technical and procedural success without increasing adverse events compared to a secondary approach.
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Medicine
Background:
- Coronary chronic total occlusions (CTOs) present a significant challenge in percutaneous coronary intervention (PCI).
- The retrograde approach offers an alternative strategy for CTO recanalization, either as an initial (primary) or subsequent (secondary) method.
- Comparing primary versus secondary retrograde CTO-PCI is crucial for optimizing procedural outcomes.
Purpose of the Study:
- To compare the clinical and angiographic characteristics of patients undergoing primary versus secondary retrograde CTO-PCI.
- To evaluate and contrast the procedural outcomes, including success rates and adverse events, between these two strategies.
- To determine if the timing of the retrograde approach impacts PCI efficacy and safety.
Main Methods:
- A retrospective analysis of 2789 CTO-PCI procedures performed between 2012 and 2021 across 34 centers.
- Patients were categorized into primary retrograde (initial strategy) and secondary retrograde (after antegrade failure) groups.
- Comparison of baseline characteristics, technical success, procedural success, and in-hospital major adverse cardiac events (MACE).
Main Results:
- The primary retrograde group (38.9%) had higher technical (81.4% vs 77.3%) and procedural success rates (78.6% vs 74.1%) compared to the secondary group (61.1%).
- Patients in the primary group had higher CTO complexity scores (J-CTO and PROGRESS-CTO) and a greater likelihood of prior coronary artery bypass graft surgery.
- No significant difference was observed in in-hospital MACE rates between the primary and secondary retrograde groups (4.3% vs 4.0%).
- Primary retrograde PCI required less contrast volume and had shorter procedure times.
Conclusions:
- Employing the retrograde approach as the primary strategy for CTO-PCI is associated with superior technical and procedural success rates.
- The primary retrograde strategy demonstrates comparable safety profiles regarding in-hospital major adverse cardiac events.
- These findings support the consideration of primary retrograde CTO-PCI in complex cases to enhance procedural efficacy.
Background:
The retrograde approach to coronary chronic total occlusions (CTOs) can be used as the initial crossing strategy (primary retrograde) or after failure of antegrade crossing attempts (secondary retrograde).
Methods:
We compared baseline clinical and angiographic characteristics and procedural outcomes of primary vs secondary retrograde crossing for CTO percutaneous coronary intervention (PCI) among 2789 procedures performed at 34 centers between 2012 and 2021.
Results:
Retrograde CTO-PCI was performed as the primary crossing strategy in 1086 cases (38.9%) and as a secondary approach in 1703 cases (61.1%). Patients in the primary group had slightly lower left ventricular ejection fraction (49.1% vs 50.4%; P=.02), were more likely to have had prior coronary artery bypass graft surgery (52.9% vs 38.4%; P<.001), and had higher J-CTO (3.31 ± 0.98 vs 2.99 ± 1.09; P<.001) and PROGRESS-CTO scores (1.47 ± 0.92 vs 1.29 ± 0.99; P<.001). Technical (81.4% vs 77.3%; P=.01) and procedural success rates (78.6% vs 74.1%; P<.01) were higher in the primary retrograde group, with no difference between in-hospital major adverse event rates (4.3% vs 4.0%; P=.66). Contrast volume (250 mL [interquartile range (IQR), 176-347] vs 270 mL [IQR, 190-367]; P<.001) and procedure time (175 minutes [IQR, 127-233] vs 180 minutes [IQR, 142-236]; P<.001) were lower in the primary group.
Conclusions:
Use of retrograde approach as the primary crossing strategy is associated with higher rates of technical and procedural success and similar rates of in-hospital major adverse cardiac events compared with secondary retrograde CTO-PCI.
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