Successful chronic total occlusion procedures are on the rise, especially in high volume centers, seeing as they count on more sophisticated materials and different techniques, such the retrograde approach. However, the significant increase of success rate with this technique has also brought along an increase in associated complications.
The aim of this study was to assess the frequency and end point of primary vs secondary retrograde approach.
The PROGRESS-CTO registry was used. Primary retrograde approach was defined as cases where the first attempt at crossing was retrograde, while secondary approach was defined as crossing after failed antegrade approach.
Data from 2789 patients were obtained; mean age was 64.8, and 85% were men. The retrograde approach was used as primary strategy in 1086 of cases (38.9%), while the secondary approach, after failed first antegrade attempt, was seen in 1703 cases (61.1%). Patients in the primary group had higher CABG rate (52.9%vs38.4%; P<0.001). The artery most frequently affected was the right coronary (71%), score PROGRESS-CTO was higher in the primary group.
Secondary approach interventions lasted more (180 min vs 175 min), received more kerma radiation (1.8 Gy vs 1.4 Gy) and more contrast (270ml vs 250ml). Both technical and procedural success rate (81.4% vs 77.3%; P<0.001 and 78.6% vs 74.1%, P<0.001 respectively) were significantly higher in the primary group.
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In-hospital major cardiovascular adverse events rate (MACE) was comparable in both groups (4.3% vs 4%; P=0.66), and in-hospital death rate was low with both strategies. There were no significant differences in new revascularization rate (0.37% vs 0.59%; P=0.43), stroke (0.4% vs 0.2%; P=0.52) or perforation (8.8% vs 10.7%; P=0.11).
Conclusions
It was observed, in an important number of patients, that primary retrograde approach presented a higher technical success rate, as well as procedural, vs. the secondary approach. The retrograde approach can be the first choice of treatment in some cases, especially long CTO procedures, with tortuous occlusions and an ambiguous proximal cap. These results do not apply to all CTO cases, where we know the approach should be antegrade.
Dr. Omar Tupayachi.
Member of the Editorial Board of SOLACI.org.
Original title: Primary vs Secondary Retrograde Approach in Chronic Total Occlusion Percutaneous Coronary Interventions.
Source: Kostantinis, Spyridon et al. “Primary vs Secondary Retrograde Approach in Chronic Total Occlusion Percutaneous Coronary Interventions.” The Journal of invasive cardiology vol. 34,9 (2022): E672-E677.
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