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

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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_at_gmail.com)

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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

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OBJECTIVES

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

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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 agegt3 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

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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)

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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

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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 stenosislt30
• 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

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PATIENT DATA
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LESION AND PROCEDURAL DATA
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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)
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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.
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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
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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
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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)

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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 2421 months
  showed an overall MACE rate of 23, with 2 target
  vessel revascularizations

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OTHER SIMILAR STUDIES
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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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