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Clinical research

Retrograde approach to coronary chronic total occlusions: preliminary single European centre experience

1. Royal Brompton Hospital, Department of Cardiology, London, United Kingdom; 2. Royal Brompton Hospital, Cardiac Magnetic Resonance Unit, London, United Kingdom; 3. Toyohashi Heart Center, Department of Cardiology, Toyohashi, Japan

Aims: The retrograde approach via septal or epicardial collaterals holds promise in improving the success rate of chronic total occlusion (CTO) recanalisation but is still viewed as an esoteric practice reserved to a selected group of operators using materials not available in Western countries. We sought to introduce the novel technique of retrograde CTO recanalisation to our institution using materials and resources available outside Japan.

Methods and results: Between April 2005 and 2007, all patients with a failed antegrade attempt at CTO recanalisation were considered and selected based on their appropriateness to have a retrograde procedure. Seventeen patients were included. Average age was 65.3 years. The mean occlusion duration was 33.3 months. Successful CTO recanalisation was achieved in 15 of 17 (88.2%) patients. A retrograde wire was successfully advanced into the distal occluded vessel and facilitated successful CTO recanalisation in 13 (76.5%) patients. Final retrograde wire crossing was achieved in seven cases, while in the remaining cases, the CART technique (n=4) and ‘knuckle’ technique (n=2) were successful. In two cases (11.8%), the retrograde wire did not reach the distal occlusion because of septal tortuosity but a repeat antegrade attempt, aided by contralateral visualisation, was successful. In two (11.8%) patients, the procedure was unsuccessful. Cardiac magnetic resonance imaging performed in five of the successfully treated retrograde cases (45.5%) showed variable degrees of fibrosis in the territory of the occluded artery with no significant change after the procedure with the exception of one case of contained contrast extravasation within the septum.

Conclusions: The novel method of retrograde recanalisation of CTOs was performed with a high procedural success in this series and was applicable in 37.1% of previously failed antegrade procedures. This technique can also be successfully employed despite newly created dissections immediately following a failed antegrade attempt.

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