The retrograde approach for recanalizing chronic total occlusions (CTO) has undergone significant evolution since its introduction in 1990, improving both in terms of techniques and specialized materials. The increased skill applied to this strategy has resulted in increased success rates for the treatment of CTO in sites with an adequate volume of procedures.

Given the inherent complexity of the retrograde approach, it has historically been associated with lower success rates and a higher incidence of complications. This study sought to assess the results of the retrograde approach through a multicenter CTO registry (PROGRESS-CTO).

Researchers conducted a prospective registry analysis in high-volume centers distributed across 44 locations, including the United States, Canada, Egypt, Greece, Russia, and Turkey, where the retrograde approach was applied as the primary or secondary approach. The analyzed parameters included quality of the distal vessel, calcification presence and degree, and proximal tortuosity.

The main indicators assessed were technical success, defined as revascularization with residual stenosis ≤30%, and procedural success, defined as technical success without in-hospital adverse events (death, myocardial infarction, recurrent symptoms requiring new revascularization, bypass surgery, tamponade, or stroke).

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Out of a total of 11,808 registered CTO percutaneous coronary interventions (PCI), there were 4058 attempts at a retrograde approach. The average patient age was 64.6±10.4 years, and 84% of patients were men. There was a high prevalence of comorbidities: 89.9% of subjects had arterial hypertension, 89.1% had dyslipidemia, 69.3% had undergone prior PCI, and 42.5% had undergone prior myocardial revascularization surgery (MRS).

The right coronary artery was the most frequently treated vessel (67.4%), followed by the anterior descending artery (16.2%). The average J-CTO was 3.1±1.1, and the PROGRESS-CTO was 1.3±0.9. In 22.3% of cases, CTO treatment was attempted at least once. Additionally, 59.9% of subjects had moderate/severe calcification, 40.8% had moderate/severe proximal tortuosity, and 56.6% had proximal cap ambiguity. The average occlusion length was 4.1±24.5 mm, and most aptients had Werner class 1 collaterals (55.8%).

The retrograde approach was the primary strategy in 40.4% of lesions, with noteworthy indications such as long occlusion (35.7%), ostial involvement of the occlusion (21.3%), and presence of a lateral branch in the proximal cap (20.9%). The dissection and re-entry technique was the second most successful strategy (11.5%), followed by the antegrade approach (9.6%).

The rate for failure to cross the occlusion was 18.4%; failure advancing the guidewire through the collateral branch (64.2%) was the main cause, followed by difficulties in re-entry (19.7%) or failure advancing the microcatheter. The average technical success was 78.7%, and the procedural success was 76.6%.

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When the retrograde approach failed, technical success was achieved in 50.3% of cases using the antegrade approach. The incidence of major adverse events was 3.5%, with a clinically relevant coronary perforation rate of 5.8%. The rate for need for pericardiocentesis in those cases was 1.3%.

There were no significant differences in in-hospital adverse events among various techniques when they were successful (2.3% for retrograde, 3.5% for antegrade, and 3.4% for retrograde; P=0.38). Retrograde true lumen puncture was achieved in 31.8%, followed by reverse controlled antegrade and retrograde tracking (CART) (34.4%) and reverse CART with guide catheter extension (19.4%). The most frequently used collaterals were septal (62%), saphenous vein grafts (17.4%), or contralateral collaterals (15.7%), with no significant differences in adverse events based on the chosen collateral.

Conclusions

Lesion complexity and complication rates were significant in this cohort with adequate experience, and the procedural success rates were moderate (60.5%). However, retrograde true lumen crossing proved to be safer compared with dissection and re-entry techniques.

Dr. Omar Tupayachi.
Member of the Editorial Board of SOLACI.org.

Original Title: The Retrograde Approach to Chronic Total Occlusion Percutaneous Coronary Interventions.

Reference: Allana, S, Kostantinis, S, Rempakos, A. et al. The Retrograde Approach to Chronic Total Occlusion Percutaneous Coronary Interventions: Technical Analysis and Procedural Outcomes. J Am Coll Cardiol Intv. 2023 Nov, 16 (22) 2748–2762. https://doi.org/10.1016/j.jcin.2023.08.031.

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