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Clinical research

European experience with the retrograde approach for the recanalisation of coronary artery chronic total occlusions.

1. Erasmus MC, Thoraxcenter, Rotterdam, The Netherlands; 2. Royal Brompton Hospital and Imperial College, London, United Kingdom; 3. Heart Centre, Bad Krozingen, Germany; 4. Ospedale Ferrarotto, University of Catania, Catania, Italy; 5. Hamburg University Cardiovascular Center, Hamburg, Germany; 6. Klinikum Darmstadt, Darmstad, Germany; 7. Institut Cardiovasculaire Paris Sud, Massy, Paris, France; 8. Main Taunus Heart Institute, Bad Soden, Germany

Aims: Recanalisation rates of coronary chronic total occlusions (CTO) remain sub-optimal. The retrograde technique was recently introduced to improve success rates.

Methods and results: From February 2005 until December 2007, 175 patients were treated with this technique in seven European centres by highly experienced operators: in 84 (48%) as primary strategy, in 41 (23.5%) immediately after antegrade failure and in 50 (28.5%) as a repeat procedure after previous antegrade failure.

Baseline characteristics revealed a mean age 61.4±10.8 years with 29.5% and 39% of patients having diabetes and a prior history of MI, respectively. The mean occlusion duration was 50.8 months (determined in 32% of patients). The target vessel was: LAD 21%, LCX 6.3%, RCA 71.4%. Epicardial collaterals were accessed in 20.6% and septal in 79.4% of the patients. Overall success rate was 83.4%. In 80.6% a wire crossed the collaterals and successfully delivered distal to the occlusion; success rate in this group was 91.5%. The technique implemented in the retrograde facilitated successful recanalisation was: retrograde wire/balloon crossing in 28%, CART in 34% and marker wire/“knuckle” technique in 48%. There was a great diversity between centres referring to the retrograde technique used. According to the initial strategy success rates were: primary 89.3%, immediately after antegrade failure 65.9% and repeat procedure after antegrade failure in 88%. In patients with failure to cross the collaterals success rate was 50%.

Septal rupture/haematoma occurred in 6.9% of the patients, periprocedural myocardial infarction (CK-MB rise) in 4% and TIA in 0.6% and wire entrapment in 0.6%. Mean fluoroscopy time was 59.3 mn and the mean contrast used was 420.9 ml. Drug eluting stents were implanted in all successfully recanalised vessels.

Conclusions: There is great diversity amongst European centres with respect to how the retrograde strategy has been adopted and adapted. The retrograde approach was used with high degree of success and safety and can thus be regarded as a valid contributor to the armamentarium of the modern day interventional cardiologist.

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