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The Retrograde Approach to Chronic Total Occlusion Percutaneous Coronary Interventions: Technical Analysis and
Salman S Allana1, Spyridon Kostantinis1, Athanasios Rempakos1
1Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA.
Insights
Retrograde chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is complex, with moderate success and significant complication rates. Retrograde true lumen puncture offers the safest approach among techniques, highlighting the need for improved efficacy and safety.
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Medicine
Background:
- Retrograde chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is often associated with lower success rates and higher complication risks compared to the antegrade approach.
- CTO lesions represent a significant challenge in coronary interventions, demanding advanced techniques for successful revascularization.
Purpose of the Study:
- To evaluate contemporary techniques and clinical outcomes of retrograde CTO PCI.
- To assess the safety and efficacy of various retrograde crossing strategies in complex CTO cases.
Main Methods:
- A retrospective analysis of 4,058 retrograde CTO PCIs performed across 44 centers from 2012 to 2023.
- Data collection included baseline characteristics, procedural techniques, and in-hospital outcomes, with major adverse cardiac events (MACE) defined as death, myocardial infarction, repeat revascularization, pericardiocentesis, cardiac surgery, or stroke.
Main Results:
- The average J-CTO score was 3.1 ± 1.1, indicating complex lesions. Retrograde crossing success was 60.5%, with lesion crossing achieved in 81.6%.
- Technical and procedural success rates were 78.7% and 76.6%, respectively. In-hospital MACE was 3.5% and the clinical coronary perforation rate was 5.8%.
- Retrograde true lumen crossing demonstrated the lowest in-hospital MACE incidence (2.1%) compared to other techniques.
Conclusions:
- Retrograde CTO PCI is employed for highly complex cases, achieving moderate success rates but carrying notable perforation (5.8%) and MACE (3.5%) risks.
- Retrograde true lumen puncture emerged as the safest crossing strategy. Further advancements are necessary to enhance both the efficacy and safety of retrograde CTO PCI procedures.
Background:
Retrograde chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is associated with lower success and higher complication rates when compared with the antegrade approach.
Objectives:
This study sought to assess contemporary techniques and outcomes of retrograde CTO PCI.
Methods:
We examined the baseline characteristics, procedural techniques and outcomes of 4,058 retrograde CTO PCIs performed at 44 centers between 2012 and 2023. Major adverse cardiac events (MACE) included any of the following in-hospital events: death, myocardial infarction, repeat target vessel revascularization, pericardiocentesis, cardiac surgery, and stroke.
Results:
The average J-CTO (Multicenter CTO Registry in Japan) score was 3.1 ± 1.1. Retrograde crossing was successful in 60.5% and lesion crossing in 81.6% of cases. The collaterals pathways successfully used were septals in 62.0%, saphenous vein grafts in 17.4%, and epicardials in 19.1%. The technical and procedural success rates were 78.7% and 76.6%, respectively. When retrograde crossing failed, technical success was achieved in 50.3% of cases using the antegrade approach. In-hospital MACE was 3.5%. The clinical coronary perforation rate was 5.8%. The incidence of in-hospital MACE with retrograde true lumen crossing, just marker antegrade crossing, conventional reverse controlled antegrade and retrograde tracking (CART), contemporary reverse CART, extended reverse CART, guide-extension reverse CART, and CART was 2.1%, 0.8%, 5.5%, 3.0%, 2.1%, 3.2%, and 4.1%, respectively; P = 0.01).
Conclusions:
Retrograde CTO PCI is utilized in highly complex cases and yields moderate success rates with 5.8% perforation and 3.5% periprocedural MACE rates. Among retrograde crossing strategies, retrograde true lumen puncture was the safest. There is need for improvement of the efficacy and safety of retrograde CTO PCI.
