Incidence, Predictors, and Strategies for Retrograde Wire Tracking Failure via Poor Septal Collateral Channels in Chronic Total Occlusion

Background

Retrograde guidewire (GW) tracking success via a poor septal collateral channel (CC) when an antegrade approach fails is crucial for successful revascularization of coronary chronic total occlusion (CTO) with poor septal CC. However, the incidence, predictors, and management strategies for retrograde GW tracking failure via poor septal CC remain unclear.

Methods

In total, 122 CTO patients who underwent retrograde septal percutaneous coronary intervention (PCI) with poor CC between January 2017 and May 2022 were retrospectively analyzed. Patients were divided into the retrograde GW tracking success group (success group) and the retrograde GW tracking failure group (failure group). Clinical and angiographic data were compared to investigate the predictors of retrograde GW tracking failure.

Results

The incidence of GW tracking failure was 22.1% (27/122). Patients in the failure group had a higher prevalence of left anterior descending artery (LAD) CTO (66.7% vs 37.9%; p = 0.009) and a higher incidence of well-developed non-septal collateral (66.7% vs 30.5%; p = 0.001). Patients with a septal CC diameter ≥ 1 mm (48.1% vs 70.5%; p = 0.040), ≥ 3 septal CCs (44.4% vs 66.3%; p = 0.046), and initial retrograde application of Guidezilla (37.0% vs 60.0%; p = 0.048) were significantly lower in the failure group than in the success group. The binary logistics regression model showed that a CC diameter < 1 mm, well-developed non-septal collateral, and LAD CTO were independent predictors for GW tracking failure in patients undergoing retrograde CTO PCI via poor septal CC.

Conclusion

The success rate of retrograde GW tracking via poor septal CC was high, with a relatively high procedural success rate. A CC diameter < 1 mm, well-developed non-septal collateral, and LAD CTO were independent predictors of GW tracking failure in patients undergoing retrograde CTO PCI via poor septal CC.

A Novel Parallel Wire-based Antegrade Dissection Re-entry Technique for Failed Retrograde Attempt of Coronary Chronic Total Occlusions with Risk Nomogram Analysis

BACKGROUND

Rapid development in coronary chronic total occlusion (CTO) interventional techniques and devices have achieved a greater success rate with favorable outcomes. Antegrade dissection re-entry (ADR) technique is an important CTO crossing strategy and a desirable approach for long CTOs with good distal landing zone. However, unsuccessful procedures in contemporary CTO-percutaneous coronary intervention (PCI) remain, especially in lesions with non-interventional collaterals.

METHOD

Based on a single center experience, a hybrid interventional algorithm, parallel wire-based ADR (PW-ADR) combines the advantages of parallel wire technique (PWT) and device-based ADR to target CTO lesions with failed retrograde approach. A retrospective analysis of patients who underwent PW-ADR was performed. A risk nomogram was created to identify patients at high risk for technical failure.

RESULTS

A total of 57 patients treated with PW-ADR were ultimately included in the present study. A total of 46 (80.7%) cases achieved technical success and procedural success, with low incidence of in-hospital complications or 1-year major adverse cardiac events (MACE). The risk nomogram identified 3 predictor variables associated with technical failure of PW-ADR, including tortuous vessel, J-CTO score, and times of antegrade coronary angiography (CAG) during ADR, with promising accuracy (AUROC 0.947).

CONCLUSION

The novel hybrid CTO-PCI algorithm, PW-ADR, provided an alternative interventional approach for complex CTO lesions with a promising success rate. The risk nomogram served as a prompter for high-risk cases, which may warrant a change in treatment strategy.

Antegrade versus Retrograde Approach for Recanalization of Ostial or Stumpless Coronary Chronic Total Occlusion

Purpose

This research aimed to evaluate the procedural and in-hospital clinical outcomes of percutaneous coronary intervention (PCI) for ostial or stumpless chronic total occlusion (CTO) utilizing both the antegrade-only and retrograde approaches.

Methods

A comprehensive retrospective examination was conducted on the procedural and in-hospital clinical outcomes of 89 consecutive patients subjected to ostial or stumpless CTO PCI at our institution between April 2015 and October 2022.

Results

The antegrade-only technique demonstrated a superior technical success rate (92.0% vs 71.9%, p = 0.041) and procedural success rate (92.0% vs 68.8%, p = 0.022) in comparison to the retrograde approach (RA). The RA group presented a notably elevated Japanese-CTO (J-CTO) score relative to the antegrade-only approach group (2.45±0.73 vs 1.64±0.70, p < 0.001). The antegrade-only approach group manifested an increased frequency of microchannels at the proximal stump relative to the RA group (56.0% vs 10.9%, p < 0.001). In-hospital major adverse cardiac events (MACE) and in-hospital myocardial infarction (MI) were observed more prevalently in the RA group (18.8% vs 0, p = 0.003; 15.6% vs 0, p = 0.008; respectively). A J-CTO score below 2 and the manifestation of microchannels at the proximal stump were identified as predictors for successful antegrade-only approach PCI for ostial or stumpless CTO (OR: 2.79 [95% CI: 1.92-5.03, P =0.003]; OR: 2.89 [95% CI: 1.32-6.03, P =0.001]; respectively).

Conclusion

Relative to RA PCI for ostial or stumpless CTO, the antegrade-only approach is utilized for less complex CTO lesions and is associated with a diminished probability of in-hospital MACE.

Retrograde Chronic Total Occlusion Percutaneous Coronary Interventions: Predictors of Procedural Success From the ERCTO Registry

OBJECTIVES

The aim of this study was to identify independent predictors of procedural success after retrograde chronic total occlusion (CTO) percutaneous coronary intervention (PCI).

BACKGROUND

Retrograde CTO PCI is an established technique, but predictors of success remain poorly understood.

METHODS

A multivariable logistic regression model was used to analyze potentially important demographic, clinical, anatomical, and technical aspects of retrograde CTO PCI cases uploaded to the multicenter European CTO (ERCTO) Club Registry.

RESULTS

In calendar years 2018 and 2019, 2,364 retrograde CTO PCI cases constituted the primary analysis cohort. A primary retrograde strategy was used in 1,953 cases (82.6%), and an initial antegrade approach was converted to retrograde in 411 cases (17.4%). Procedural success was achieved in 1,820 cases (77.0%) and was more likely to occur after a primary retrograde attempt versus conversion from an initial antegrade approach (80.9% vs 58.4%; P < 0.0001). After multivariable analysis, an absence of lesion calcification (OR: 1.86; 95% CI: 1.37-2.51; P < 0.0001), a higher degree of distal vessel opacification (OR: 2.47; 95% CI: 1.72-3.55; P < 0.0001), little or no proximal target vessel tortuosity (OR: 1.84; 95% CI: 1.28-2.64; P = 0.001), Werner collateral connection CC1 (OR: 4.87; 95% CI: 2.90-8.19; P < 0.0001) or CC2 (OR: 5.33; 95% CI: 3.02-9.42; P < 0.0001), and the top tertile of operator volume (>120 cases over 2 years) (OR: 1.88; 95% CI: 1.26-2.79; P = 0.002) were associated with the greatest chance of achieving angiographic success.

CONCLUSIONS

Less calcification with good distal vessel opacification, little or absent proximal vessel tortuosity, and visible collateral connections, along with high-volume operator status, were all independently predictive of angiographically successful retrograde CTO PCI.

Retrograde endovascular revascularization for chronic total occlusion of the internal carotid artery: a case report

Endovascular revascularization of a chronically occluded internal carotid artery (ICA) is challenging because the occlusive segment can be long and tortuous. A case is presented of a successful recanalization of a chronically occluded ICA by retrograde passing of a guidewire from the intracranial ICA to the cervical ICA via the posterior communicating artery. This case suggests that a retrograde approach for reopening an occluded artery may be useful during neurovascular interventions, similar to percutaneous coronary interventions. In this patient, daily transient ischemic attacks disappeared after successful recanalization of the ICA.

Impacts of Lesion Characteristics on Procedures and Outcomes of Chronic Total Occlusion Recanalization With Antegrade Guidewire True Lumen Tracking Techniques: A Substudy of Taiwan True Lumen Tracking Registry

Background

Lesion characteristics were shown to predict procedural success and outcomes in chronic total occlusion (CTO) recanalization. However, diverse techniques involved in these studies might cause potential heterogeneity.

Objective

The study aimed to test the impacts of lesion characteristics on CTO intervention with a pure antegrade wiring-based technique.

Methods and Results

We studied consecutive 325 patients (64.5 ± 11.1 years, 285 men) with native CTO lesions intervened by a single operator with an antegrade-based technique between August 2014 and July 2020. Forty-seven patients with antegrade procedural failure (20 with pure antegrade wiring failure and 27 with back-up retrograde techniques) were compared to 278 patients with antegrade-only procedural success. With a median follow-up of 30.8 (16.1–48.6) months, 278 patients with procedural success were further assessed for target vessel failure (TVF: cardiac death, target vessel myocardial infarction [MI], and target lesion revascularization [TLR]). Patients with antegrade procedural success had a lower percentage of history with bypass graft (4 vs. 15%, p = 0.004) and lower Multicenter Chronic Total Occlusion Registry of Japan (J-CTO) score (2.1±1.3 vs. 3.4 ± 1.0, p < 0.001), when compared to those with antegrade failure. The J-CTO score was independently associated with procedural failure (odds ratio = 2.5, 95% CI = 1.8–3.4) in multivariate analysis. However, only clinical features, such as female gender (hazard ratio [HR] = 4.3, 95% CI = 1.4–13.1), estimated glomerular filtration rate <60 ml/min/1.73 m² (HR = 3.2, 95% CI = 1.0–9.9), and old MI (HR = 4.5, 95% CI = 1.5–12.8), but not J-CTO score, could predict long-term TVF in multivariate Cox regression model.

Conclusion

The feasibility of the antegrade guidewire-crossing technique for native CTO intervention was highly determined by lesion characteristics. With such a simpler technique, the prognostic impact of lesion complexity shown in studies with multiple recanalization techniques was negligible. This suggested antegrade true lumen tracking techniques deserved to be tried better even for CTO lesions with higher complexity.

Primary versus rescue retrograde approach for chronic total coronary occlusion

OBJECTIVES

We aimed to assess the advantages of using the retrograde approach as an initial strategy rather than as a rescue strategy for complex chronic total occlusions (CTOs).

BACKGROUND

Even for complex CTOs where a retrograde approach is deemed necessary, an antegrade approach is frequently used as an initial strategy in real-world practice.

METHODS

We evaluated 352 retrograde procedures for CTO conducted at our high-volume center between January 2007 and January 2019. Procedural efficiency and safety was assessed based on the guidewire manipulation time (GWMT) and the occurrence of procedure-related adverse events for the primary retrograde approach (PRA) and the rescue retrograde approach (RRA).

RESULTS

PRA and RRA were used in 191 (54.3%) and 161 (45.7%) of the CTO procedures, respectively. The complexity of the CTO lesion was significantly higher in the PRA group than in the RRA group (Japanese-CTO score, 2.62 ± 1.07 vs. 2.38 ± 1.06, p = 0.037). The technical success rate of two groups was similar (p = 0.47). The median GWMT required for PRA was significantly shorter than that for RRA (85 [interquartile range, 55-126] vs. 120 [85-157] min, p < 0.001). The total duration of the procedure and fluoroscopic time were shorter, and the number of guidewires and amount of contrast used during the index procedure were smaller in the PRA group. The incidence of procedure-related adverse events was not significantly different between the two groups.

CONCLUSIONS

PRA showed higher procedural efficiency than RRA with comparable safety. Opting for PRA for complex CTOs might be a rational decision to enhance the procedural efficiency.

Clinical outcomes of post-stent intravascular ultrasound examination for chronic total occlusion intervention with drug-eluting stents

BACKGROUND

Few studies have evaluated intravascular ultrasound (IVUS) use in chronic total occlusion (CTO) percutaneous coronary intervention (PCI).

AIMS

In CTO-PCI, we aimed to (1) evaluate the clinical benefits of performing post-stent IVUS in preventing adverse clinical events, and (2) identify IVUS parameters and cut-off values for prediction of target lesion revascularisation (TLR)/reocclusion.

METHODS

A total of 1,077 patients with 1,077 CTO lesions treated with drug-eluting stents (DES) were included. Clinical outcomes during a median follow-up of 6.3 years were compared between subjects with and those without post-stent IVUS using the inverse probability weighting method.

RESULTS

Of 1,077 patients, post-stent IVUS was performed in 838 (77.8%) cases while in the remaining 239 (22.2%) cases it was not. In the weighted population, the risk of TLR/reocclusion was significantly lower in subjects with post-stent IVUS (9.6% vs 18.9%, hazard ratio [HR] 0.54, 95% confidence interval [CI]: 0.34-0.86, p=0.01), compared with those without post-stent IVUS. Cox regression analysis showed that minimal stent area (MSA) measured by IVUS was the only parameter independently associated with TLR/reocclusion (HR 0.78, 95% CI: 0.64-0.95; p=0.01) and the optimal MSA cut-off value was 4.9 mm2 for prediction of TLR/reocclusion (area under the curve=0.632, p=0.001).

CONCLUSIONS

In CTO-PCI with DES, post-stent IVUS evaluation was associated with a lower risk of TLR/reocclusion. The final MSA was independently associated with TLR/reocclusion with a cut-off value of 4.9 mm2.

Rotational Atherectomy-Assisted Crossing of a Complex Right Coronary Artery Lesion Using the Retrograde Approach

Chronic total occlusion lesions present a major challenge for the interventional cardiologist. In this case, we report the successful use of rotational atherectomy to facilitate retrograde percutaneous coronary intervention of a complex totally occluded right coronary artery after modification of the proximal cap of the lesion to enable placement of the RotaWire in the vessel architecture.

Complications during chronic total occlusion percutaneous coronary intervention: a sign- and symptom-based approach to early diagnosis and treatment

Coronary chronic total occlusions (CTO) are frequently found in patients undergoing coronary angiography. Despite their high prevalence and indication for revascularization in a relevant proportion of cases, CTO recanalization is attempted only in a minority of cases. This is due to higher risk of procedural complications compared to non-CTO interventions and because the CTO-PCIs are the most complex procedures in interventional cardiology. In particular, the perceived higher risk of complications during CTO intervention might discourage new operators from engaging in this challenging field. The aim of this work is to review the potential complications of CTO percutaneous coronary intervention, and to provide an algorithmic, sign- and symptom-based approach to facilitate early recognition and effective management.

Antegrade versus retrograde techniques for Chronic Total Occlusions (CTO): a review and comparison of techniques and outcomes

Introduction: As the field of chronic total occlusion percutaneous coronary intervention has evolved, technical approaches have evolved and been refined.Areas covered: In this review, we discuss the major techniques utilized in modern CTO PCI including antegrade wiring, antegrade dissection reentry, retrograde wiring, and retrograde dissection reentry. Retrograde techniques have been extensively studied in comparison to antegrade techniques. Retrograde techniques have contributed to increases in CTO PCI success rates and are generally used in higher complexity lesions. Observational data ssuggestincreased sshort-termcomplications in procedures requiring the use of retrograde techniques; however, llong-termCTO PCI durability and patient outcomes have been shown to be similar among procedures using antegrade only versus retrograde techniques.Expert opinion: Retrograde techniques play a vital role in the technical success of CTO PCI, particularly among more complex lesions and in patients with high burdens of comorbidities. Increases in procedural safety with equipment iteration and in the use of adjunctive imaging will play an important role in the selection of appropriate retrograde conduits and the overall success rates of CTO PCI.

Latest developments in chronic total occlusion percutaneous coronary intervention

INTRODUCTION

Chronic Total Occlusion Percutaneous Coronary Intervention (CTO PCI) is now performed with high success rates and acceptable complication rates.

AREAS COVERED

We describe recent clinical and technological developments in CTO PCI from 2018 to 2020.

EXPERT OPINION

After publication of six randomized controlled trials, improving patient symptoms remains the principal indication for CTO PCI. Although good outcomes can be achieved with CTO PCI at experienced centers, success rates are significantly lower at less experienced centers, despite increased use in CTO crossing algorithms and development of novel and improved equipment and techniques.

Factors associated with antegrade true-sub-true phenomenon in percutaneous coronary intervention for chronic total occlusion

Background

Recently, the importance of chronic total occlusion (CTO)-percutaneous coronary intervention (PCI) has been emphasized with greater success rates. In the antegrade wire based approach, it is generally considered that the guidewire would not advance from the subintimal space to the intimal space without dissection re-entry device. However, it is sometimes observed by intravascular ultrasound (IVUS) that the guidewire within the subintimal space advanced into the distal true lumen. The purpose of this study was to investigate specific conditions or characteristics which were associated with “antegrade true-sub-true” phenomenon in CTO-PCI.

Methods

We retrospectively reviewed consecutive 320 CTO lesions that underwent CTO-PCI in our institution. Among them, 16 lesions in which the IVUS confirmed the “antegrade true-sub-true” phenomenon were categorized as the true-sub-true group, whereas 27 lesions that resulted in unsuccessful CTO-PCI were categorized as the unsuccessful group. We compared the clinical, lesion, and procedural characteristics between the true-sub-true group and the unsuccessful group.

Results

The prevalence of bifurcation with abrupt type in CTO exit-sites was significantly higher in the true-sub-true group in comparison to the unsuccessful group (75.0% vs. 25.9%, p = 0.002). The multivariate logistic regression analysis revealed that bifurcation with abrupt type in CTO exit-site (OR 8.017; 95%CI: 1.484–43.304; p = 0.016) was independent predictor of the antegrade true-sub-true phenomenon.

Conclusions

In CTO-PCI, the antegrade true-sub-true phenomenon is rare, but can be a last chance for successful PCI. Bifurcation with abrupt type in CTO exit-site was significantly associated with the antegrade true-sub-true phenomenon.

Outcomes with retrograde versus antegrade chronic total occlusion revascularization

OBJECTIVES

The aim of the study was to evaluate the outcomes of retrograde versus antegrade approach in chronic total occlusion (CTO) percutaneous coronary intervention (PCI).

BACKGROUND

The retrograde approach has increased the success rate of CTO PCI but has been associated with a higher risk for complications.

METHODS

We conducted a meta-analysis of studies published between 2000 and August 2019 comparing the in-hospital and long-term outcomes with retrograde versus antegrade CTO PCI.

RESULTS

Twelve observational studies (10,240 patients) met our inclusion criteria (retrograde approach 2,789 patients, antegrade approach 7,451 patients). Lesions treated with the retrograde approach had higher J-CTO score (2.8 vs. 1.9, p < .001). Retrograde CTO PCI was associated with a lower success rate (80.9% vs. 87.4%, p < .001). Both approaches had similar in-hospital mortality, urgent revascularization, and cerebrovascular events. Retrograde CTO PCI was associated with higher risk of in-hospital myocardial infarction (MI; odds ratio [OR] 2.37, 95% confidence intervals [CI] 1.7, 3.32, p < .001), urgent pericardiocentesis (OR 2.53, 95% CI 1.41-4.51, p = .002), and contrast-induced nephropathy (OR 2.12, 95% CI 1.47-3.08; p < .001). During a mean follow-up of 48 ± 31 months retrograde crossing had similar mortality (OR 1.79, 95% CI 0.84-3.81, p = .13), but a higher incidence of MI (OR 2.07, 95% CI 1.1-3.88, p = .02), target vessel revascularization (OR 1.92, 95% CI 1.49-2.46, p < .001), and target lesion revascularization (OR 2.08, 95% CI 1.33-3.28, p = .001).

CONCLUSIONS

Compared with antegrade CTO PCI, retrograde CTO PCI is performed in more complex lesions and is associated with a higher risk for acute and long-term adverse events.