Application of a snare technique in retrograde chronic total occlusion percutaneous coronary intervention - a step by step practical approach and an observational study

Effectiveness and safety of a novel modified homemade snare in retrograde percutaneous coronary intervention for chronic total occlusion lesions: a retrospective cohort study

Background

The use of a commercial snare for retrograde chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is time-consuming and expensive. This study aimed to evaluate the benefits and complications of a novel modified homemade snare (MHS) for retrograde CTO-PCI.

Methods

This retrospective cohort study included patients with CTO who underwent retrograde PCI with guidewire snaring between January 2017 and June 2022 at Beijing Anzhen Hospital. The patients were divided into the MHS and gooseneck snare (GS) groups according to the devices used for externalization. Clinical, procedural, and angiographic data were collected.

Results

Ninety patients (46 with MHS and 44 with GS) were included. There was no significant difference in the location of the CTO vessel between the MHS and GS groups, and the target CTO vessel was mainly located in the right coronary artery (RCA) in both groups (73.9% and 68.2% respectively). There were no significant differences in the J-CTO (Multicenter CTO Registry in Japan) and PROGRESS-CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention) scores between the two groups. More patients in the MHS group had lesions with ambiguous proximal caps compared with the GS group (54.3% vs. 31.8%, P=0.04). Retrograde wire crossing technique was used more in the GS group (54.5% vs. 41.3%, P=0.04), while reverse-controlled antegrade and retrograde subintimal tracking (CART) technique was used more in the MHS group (58.7% vs. 45.5%, P=0.037). The mean guidewire capture time was shorter in the MHS group than in the GS group (2.7±0.6 vs. 3.4±0.7 min, P<0.001). One case of delayed pericardial tamponade was observed in the MHS group. No other complications occurred.

Conclusions

MHS appears to facilitate externalization in retrograde PCI for complex CTO lesions.

The active pulling technique to solve microcatheter-uncrossable lesions in retrograde chronic total occlusion percutaneous coronary intervention

BACKGROUND

It is not uncommon to encounter retrograde microcatheter-uncrossable lesions in retro-recanalization of Chronic Total Occlusion (CTO) cases, existing solutions were time-consuming or complicated to operate. Therefore, the present study aimed to propose and evaluate the feasibility, safety of a novel technique termed Active Pulling retrograde microcatheter crossing Technique (APT) during retrograde CTO percutaneous coronary intervention (PCI).

METHODS

We retrospectively collected retrograde CTO-PCI cases from February 2017 to April 2023, only cases with the retrograde wire successfully crossed the CTO lesion were analyzed. The baseline clinical characteristics, angiographic characteristics, procedural details, and in-hospital major adverse cardiac events (MACEs) were compared.

RESULTS

A total of 80 CTO cases were divided into the APT group and the non-APT group according to whether the APT was applied in the procedure. The APT group had a higher rate of device success than the non-APT group (100% vs. 85%, P = 0.013), with shorter duration (5.3 ± 3.8 vs. 18.6 ± 5.9 min, P < 0.001) and a smaller number of retrograde microcatheters were used (P < 0.001). In the APT group, the average air kerma radiation exposure was lower (2.7 ± 1.2 vs. 4.3 ± 1.7 Gy, P < 0.001), the fluoroscopy time (69.0 ± 15.0 vs. 88.1 ± 18.9 min, P < 0.001) and the procedure time (116.2 ± 22.2 vs. 131.6 ± 28.7 min, P = 0.009) was shorter than the non-APT group. The technical success rate of both groups reached 100% while the procedure success rate was higher in the APT group than the non-APT group (100% vs. 85%, P = 0.13).

CONCLUSIONS

The APT is an easy and safe technique that can greatly improve procedural efficiency without adding other instruments, and allows the retrograde microcatheter to quickly crossing the CTO body after successful retrograde wire externalization.

From reverse CART to antegrade wire access: a guide to externalisation, tip-in, rendezvous, and snaring from the APCTO club: Reverse CART to antegrade access

We at the Asia Pacific Chronic Total Occlusion (APCTO) club, provide this review to address the gap between reverse controlled antegrade and retrograde subintimal tracking (CART) and antegrade wire access. We describe the usual method for wire externalisation. We then address how to deal with failure to wire the proximal part of the chronic total occlusion (CTO) vessel or the guiding catheter. After successful antegrade guiding catheter wiring, we address the problem of failing to cross the CTO body with the retrograde microcatheter and we recommend the use of a retrograde small balloon, reversion to traditional CART, retrograde knuckle wiring into the subintimal space and antegrade scratch and go, and external cap crush. We also propose rendezvous type tip-in and describe the way to do this to overcome problems. In conclusion, we review and make recommendations for methods to gain antegrade wire access after successful reverse CART. We have addressed each failure mode in detail covering the different options, balancing risks and success rates. Our recommendations focus upon safety first and ease of use. We hope this work will help all retrograde operators to further improve the safety, efficacy, and success rates of their retrograde procedures.

Double trapper technique: A novel technique to facilitate retrograde wire externalization in aorto-ostial chronic total occlusion intervention without using snare

Chronic total occlusion (CTO) remains a technical challenge for the interventional cardiologists. The application of the retrograde approach has dramatically improved success rates of CTO PCI. However, retrograde wire externalization could be very difficult especially when the antegrade guiding catheter cannot sit into the coronary ostium stably. We report a novel technique to facilitate retrograde wire externalization in aorto-ostial chronic total occlusion intervention without using snare.