Retrograde Percutaneous Recanalization of Chronic Total Occlusion of the Coronary Arteries

Procedural Outcomes and Predictors of Success in Contemporary Practice

Sudhir Rathore, MD, MRCP; Osamu Katoh, MD; Hitoshi Matsuo, MD; Mitsuyasu Terashima, MD; Nobuyoshi Tanaka, MD; Yoshihisa Kinoshita, MD; Masashi Kimura, MD, PhD; Etsuo Tsuchikane, MD, PhD; Kenya Nasu, MD; Mariko Ehara, MD; Keiko Asakura, MD; Yasushi Asakura, MD; Takahiko Suzuki, MD

Background: Retrograde approach through collaterals has been introduced for percutaneous recanalization of chronic total occlusion (CTO) of the coronary arteries. We investigated the safety and efficacy of retrograde approaches used for percutaneous recanalization of CTO in a consecutive series of patients.

Methods and results: We studied 157 consecutive patients who underwent retrograde CTO recanalization between 2003 and 2008 at a single center. A total of 118 (75.2%) of these patients have had previously failed antegrade attempts. Septal, epicardial, and saphenous vein graft collaterals were used in 67.5%, 24.8%, and 7.6% of cases, respectively. Collateral channel was crossed by guide wire successfully in 115 (73.2%) cases, and the procedure was successful by retrograde approach in 103 (65.6%) cases. Collateral channels (CCs) were graded as follows: CC0, no continuous connection; CC1, continuous thread-like connection; and CC2, continuous, small sidebranch-like connection. CC1, collateral tortuosity < 90 degrees , and angle with recipient vessel < 90 degrees (P<0.0001) were significant predictors of success. Epicardial channel use (P=0.01), CC0, corkscrew channel (P<0.0001), angle with recipient vessel > 90 degrees (P=0.0007), and nonvisibility of connection with recipient vessel were found to be significant predictors of procedural failure. The CC dissection was observed in 6 patients, with 1 needing coil embolization and others who were managed conservatively. The major adverse cardiac events were low, with 1 coronary artery bypass graft, 1 Q-wave myocardial infarction, 5 non-Q-wave myocardial infarctions, and no deaths in this group of patients.

Conclusions: The retrograde approach in CTO percutaneous coronary intervention is effective in recanalizing CTO. The success rate by retrograde approach was 65.6%, and final success was 85% in this group with acceptable overall adverse events. We have identified predictors of failure related to collateral morphology.

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