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Efficacy of Primary Retrograde Approach in Complex Chronic Total Occlusions With Unfavorable Antegrade
Khaled Saber Qayed1, Cheng-Wei Lien2, Jui Wang3,4
1Cardiovascular Medicine Department, Faculty of Medicine, Assiut University.
Insights
The primary retrograde approach (PRA) improves guidewire success in complex chronic total occlusion percutaneous coronary interventions (CTO-PCI). However, PRA increases procedural time and resource use compared to the primary antegrade approach (PAA).
Area of Science:
- Cardiovascular Interventions
- Interventional Cardiology
- Vascular Medicine
Background:
- The retrograde approach is known to enhance success rates in chronic total occlusion percutaneous coronary interventions (CTO-PCI).
- The comparative efficacy of the primary retrograde approach (PRA) versus the primary antegrade approach (PAA) in complex CTO-PCI cases, particularly regarding procedural success and resource utilization, remains under investigation.
Purpose of the Study:
- To compare the efficacy of the primary antegrade approach (PAA) and the primary retrograde approach (PRA) in complex chronic total occlusion percutaneous coronary interventions (CTO-PCI).
- To evaluate procedural success rates and resource utilization between PAA and PRA in challenging CTO-PCI cases.
Main Methods:
- A single-center retrospective cohort study of 698 patients undergoing CTO-PCI by experienced operators from January 2016 to July 2023.
- Utilized the Japanese CTO score to assess antegrade approach difficulty and the collateral channel score for interventional collateral feasibility.
- Compared outcomes between PAA and PRA in 380 patients with a Japanese CTO score ≥3 and a collateral channel score ≥2.
Main Results:
- Overall technical and initial guidewire success rates were 91.4% and 83.8%, respectively.
- In complex cases (Japanese CTO score ≥3, collateral channel score ≥2), initial guidewire success was significantly higher with PRA (88.1%) than PAA (78.9%; P=0.01).
- Bail-out success was also higher with the retrograde approach (91.2%) compared to the antegrade approach (56%; P=0.0019), though PRA was associated with increased guidewire crossing time, fluoroscopy time, and contrast use.
Conclusions:
- In challenging CTO-PCI cases with poor antegrade conditions and feasible collaterals, the primary retrograde approach (PRA) demonstrates superior initial guidewire success.
- The enhanced success with PRA comes at the cost of increased procedural burden, including longer procedure times and greater resource consumption.
Background:
The retrograde approach improves the procedural success rate of chronic total occlusion percutaneous coronary interventions (CTO-PCIs). However, it remains unclear whether the primary retrograde approach (PRA) offers benefits in terms of procedural success and burden/resource use in challenging cases. Therefore, we compared efficacy between the primary antegrade approach (PAA) and PRA in complex CTO-PCIs.
Methods And Results:
This single-center retrospective cohort study included all patients undergoing coronary CTO-PCI attempted by experienced high-volume operators between January 2016 and July 2023. The difficulty of the antegrade approach was determined using the Japanese CTO score, and the feasibility of interventional collaterals was determined using the collateral channel score. In 698 patients undergoing CTO-PCI, the overall technical and initial guidewire success rates were 91.4% and 83.8%, respectively. Of 380 patients with a Japanese CTO score ≥3 and a collateral channel score ≥2, PAA and PRA were performed in 161 (42.4%) and 219 (57.6%) patients, respectively. Initial guidewire success was higher with PRA than PAA (88.1% vs. 78.9%; P=0.01), and bail-out success was higher for a retrograde than antegrade approach (91.2% vs. 56%; P=0.0019). PRA was associated with longer guidewire crossing time, longer fluoroscopy time, and greater contrast use.
Conclusions:
In patients with challenging CTO, poor antegrade conditions, and feasible interventional collaterals, PRA achieved higher initial guidewire success at the expense of higher procedural burden/resource use.
