Retrograde Percutaneous Recanalization Of Coronary Chronic Total Occlusions: Outcomes And Technical Tips & Tricks Fr

1. Retrograde Percutaneous Recanalization Of Coronary Chronic Total Occlusions: Outcomes And Technical Tips & Tricks From 17 Patients G. BIONDI-ZOCCAI, C. MORETTI, F. SCIUTO,P. OMEDE’, M. BOLLATI, A. GAMBINO, M. REVIGLIONE, P. LOMBARDI, D. SILLANO, P. GARRONE,G. TREVI, AND I. SHEIBAN University of Turin, Turin, Italy (gbiondizoccai@gmail.com)

2. BACKGROUND • Given their suboptimal success rates, coronary chronic total occlusions (CTO) represent one of the last challenges of percutaneous coronary intervention (PCI) • Among several novel techniques, the retrograde approach is one of the most promising, but it is still incompletely described

3. OBJECTIVES • We aimed to report our 5-year experience in retrograde PCI for CTOs • We also searched similar published studies

4. METHODS • We retrieved details of patients in whom retrograde coronary recanalization had been attempted at our Institution for CTO (defined as total occlusion with Thrombolysis In Myocardial Infarction [TIMI] flow 0 and age>3 months or undetermined) between January 2003 and February 2007 either after a failed antegrade attempt or electively • The clinical indication could vary from a recent episode of unstable coronary disease in a patient with multivessel involvement and CTO in a non-culprit lesion, to chronic stable angina or extensive silent myocardial ischemia • In all cases, the patients were fully informed about the risks and alternatives to the procedure, and provided written informed consent

5. METHODS • Six to 8 French guiding catheters were used antegradely and 6 Fr guiding catheters were used for retrograde accesses, usually by means of percutaneous transfemoral approaches • The coronary collateral that appeared most suitable for catheterization was tentatively accessed. While size is was an important consideration, the pathway and angulation are also very important. In the case of the presence of more than one potential collateral pathway, each collateral branch was tentatively engaged until the target occlusion was accessed retrogradely or until definite failure occurred • A 150 cm or 300 cm 0.014” hydrophilic floppy guidewire (Choice PT, Boston Scientific) was used for retrograde access, supported by a 1.5 mm over-the-wire balloon (Maverick, Boston Scientific)

6. METHODS • In a few cases the hydrophilic floppy wire was exchanged for a more supportive 0.014” guidewire dedicated for CTOs (Shinobi, Cordis). In addition, the over-the-wire balloon, either the 1.5 mm one or a smaller 1.25 mm balloon (Avion Plus, Invatec), was used occasionally to gently dilate collateral branches in case of significant resistance to balloon advancement • After retrograde deployment of the guidewire and balloon system in the distal tract of the target coronary artery, the guidewire was gently advanced retrogradely through the occlusion, in order to reach the true lumen at the ostium of the coronary artery and then deposited in the ascending aorta • Only in selected more challenging cases was a subintimal angioplasty technique used retrogradely

7. METHODS • After complete retrograde crossing, the over-the-wire balloon was used to predilate the CTO, enabling recanalization by the anterograde route with another wire, including the workhorse BMW wire (Guidant). Then, further dilations with larger balloons advanced antegradely were performed, followed by stenting • Angiographic success was defined as restoration of antegrade flow (TIMI grade 3), without persisting angiographic complications (eg grade C-F dissection or perforation), and a final residual stenosis<30% • Procedural success was defined as angiographic success in the absence of in-hospital MACE, ie cardiac death, non-fatal myocardial infarction, or target vessel revascularization • We also adjudicated the post-discharge occurrence of MACE at the longest follow-up available

8. PATIENT DATA

9. LESION AND PROCEDURAL DATA

10. The identification of the most suitable collateral vessel is based on size, pathway and angulation. In this case of a 67-year-old male with stable angina and total occlusion of the right coronary artery (* in A) with extensive collaterals from the left coronary system (B), an atrial branch of the left circumflex was first attempted for retrograde access (C-D), but due to failure on this route, the procedure was then completed through a septal collateral branch of the left anterior descending (E-F). The arrowhead shows the guidewire in the left circumflex branch, and the arrow shows the guidewire later placed in the left anterior descending branch)

11. Technical tips and tricks for a successful retrograde recanalization of chronic total occlusions. A: a low pressure inflation (arrowhead) may increase the likelihood of true lumen re-entry. B: to confirm the intended position of the balloon, it is sometimes also useful to perform a small injection of contrast through the balloon (*). C: in case of failure, even a retrograde subintimal technique can be employed, with caution advancement of the wire loop (arrow) in order to avoid dissection of the right coronary artery ostium and/or ascending aorta. D: use of two wires is recommended to increase the likelihood of recanalization. E-F: an uncommon bail-out indication for retrograde Recanalization after antegrade subintimal angioplasty with suboptimal antegrade flow in the posterior descending artery.

12. Additional technical tips and tricks for the retrograde coronary approach. A: use of a retrograde wire and two antegrade wires is sometimes needed to adequately protect an involved trifurcation. B-C: antegrade recanalization of a chronic total occlusion of the right coronary artery followed by retrograde recanalization of a chronic total occlusion of the left circumflex. D-E: accurate angiographic documentation of the collateral pathway is pivotal for successful wiring (in this case we can follow by precise panning the antegrade contrast injection in the patent right coronary artery and the retrograde filling by collateral vessels of the proximally occluded left circumflex). F: an uncommon case of retrograde recanalization of chronic total occlusion of the left circumflex through right coronary collaterals

13. Use of retrograde recanalization may increase the likelihood of complete revascularization in multivessel disease and even reduce overall procedural time. This 74-year-old man, with chronic total occlusions of the left anterior descending (LAD) and right coronary artery (RCA), as well as significant stenosis of the left circumflex (LCX) (A-C), underwent during the same procedure revascularization of the LCX, antegrade recanalization of the LAD occlusion, and then, through wiring of a LCX branch, retrograde recanalization of the RCA occlusion (D-F). The arrow shows the retrogradely tracked guidewire and balloon

14. RESULTS • The retrograde approach was attempted in 17 cases, 11 as bail-out after antegrade failure and 6 electively: 9 CTOs of right coronary artery (RCA), 2 of left circumflex (LCX), and 2 of left main (LM) • Successful retrograde deployment of the guidewire and balloon system distally to the CTO was possible in 14 (82%) patients. Specifically, the guidewire-balloon system could not deployed in 2 because of small sized branches, and in 1 the system was retrieved from the septal collateral before reaching the CTO because of septal hematoma with contrast extravasation due to balloon-induced trauma (this patient eventually recovered without any major complication)

15. RESULTS • Angiographic success was obtained in 13 cases (76%), as in an additional patient, despite complete retrograde crossing of the CTO, no proximal lumen re-entry could be achieved • Given the occurrence of a non-Q myocardial infarction in a further patient having angiographic success, the overall procedural success rate was 71% (12 cases) • Accordingly, in-hospital MACEs occurred in one patient only (the above mentioned non-fatal infarction) • Long-term clinical follow-up at 24±21 months showed an overall MACE rate of 23%, with 2 target vessel revascularizations

16. OTHER SIMILAR STUDIES

17. CONCLUSIONS • This case series, plus other similar studies, supports the feasibility and safety of the retrograde approach in the percutaneous management of highly selected patients with coronary total occlusions • By exploiting and at the same time safeguarding the coronary segments located distally to the occluded segment, this technique can be envisioned as a promising alternative strategy when aggressive antegrade approaches fail or are deemed unsafe

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