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Observational Study
. 2016 Jun;9(6):10.1161/CIRCINTERVENTIONS.115.003434 e003434.
doi: 10.1161/CIRCINTERVENTIONS.115.003434.

Outcomes With the Use of the Retrograde Approach for Coronary Chronic Total Occlusion Interventions in a Contemporary Multicenter US Registry

Dimitri Karmpaliotis  1 , Aris Karatasakis  1 , Khaldoon Alaswad  1 , Farouc A Jaffer  1 , Robert W Yeh  1 , R Michael Wyman  1 , William L Lombardi  1 , J Aaron Grantham  1 , David E Kandzari  1 , Nicholas J Lembo  1 , Anthony Doing  1 , Mitul Patel  1 , John N Bahadorani  1 , Jeffrey W Moses  1 , Ajay J Kirtane  1 , Manish Parikh  1 , Ziad A Ali  1 , Sanjog Kalra  1 , Phuong-Khanh J Nguyen-Trong  1 , Barbara A Danek  1 , Judit Karacsonyi  1 , Bavana V Rangan  1 , Michele K Roesle  1 , Craig A Thompson  1 , Subhash Banerjee  1 , Emmanouil S Brilakis  2
Affiliations
Observational Study

Outcomes With the Use of the Retrograde Approach for Coronary Chronic Total Occlusion Interventions in a Contemporary Multicenter US Registry

Dimitri Karmpaliotis et al. Circ Cardiovasc Interv. 2016 Jun.

Abstract

Background: We sought to examine the efficacy and safety of chronic total occlusion percutaneous coronary intervention using the retrograde approach.

Methods and results: We compared the outcomes of the retrograde versus antegrade-only approach to chronic total occlusion percutaneous coronary intervention among 1301 procedures performed at 11 experienced US centers between 2012 and 2015. The mean age was 65.5±10 years, and 84% of the patients were men with a high prevalence of diabetes mellitus (45%) and previous coronary artery bypass graft surgery (34%). Overall technical and procedural success rates were 90% and 89%, respectively, and in-hospital major adverse cardiovascular events occurred in 31 patients (2.4%). The retrograde approach was used in 539 cases (41%), either as the initial strategy (46%) or after a failed antegrade attempt (54%). When compared with antegrade-only cases, retrograde cases were significantly more complex, both clinically (previous coronary artery bypass graft surgery prevalence, 48% versus 24%; P<0.001) and angiographically (mean Japan-chronic total occlusion score, 3.1±1.0 versus 2.1±1.2; P<0.001) and had lower technical success (85% versus 94%; P<0.001) and higher major adverse cardiovascular events (4.3% versus 1.1%; P<0.001) rates. On multivariable analysis, the presence of suitable collaterals, no smoking, no previous coronary artery bypass graft surgery, and left anterior descending artery target vessel were independently associated with technical success using the retrograde approach.

Conclusions: The retrograde approach is commonly used in contemporary chronic total occlusion percutaneous coronary intervention, especially among more challenging lesions and patients. Although associated with lower success and higher major adverse cardiovascular event rates in comparison to antegrade-only crossing, retrograde percutaneous coronary intervention remains critical for achieving overall high success rates.

Keywords: complication; coronary occlusion; outcome; percutaneous coronary intervention.

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Figures

Figure 1
Figure 1
Flow-chart depicting the crossing strategies utilized for recanalization of the study lesions.
Figure 2
Figure 2
Technical and procedural success rates overall, for retrograde and for antegrade-only cases.
Figure 3
Figure 3
Box plots for contrast, radiation and procedure time of the study procedures, classified according to whether retrograde techniques were used or not. Lines represent minimum, 25th centile, median, 75th centile and maximum values.
Figure 4
Figure 4
Incidence of in-hospital major adverse cardiovascular events of the study procedures, classified according to whether retrograde techniques were used or not. (MACE, major adverse cardiovascular events; MI, myocardial infarction; PCI, percutaneous coronary intervention)
Figure 5
Figure 5
Predictors of technical success for retrograde CTO PCI (CABG, coronary artery bypass graft; CTO, chronic total occlusion; LAD, left anterior descending; LCX, left circumflex; MACE, major adverse cardiovascular events; MI, myocardial infarction; PCI, percutaneous coronary intervention; RCA, right coronary artery)
Figure 6
Figure 6
Temporal trends in utilization of antegrade wire escalation, antegrade dissection/ re-entry and the retrograde approach.
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