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Retrograde Techniques and the Impact of Operator Volume on Percutaneous Intervention for Coronary Chronic Total Occlusions

An Early U.S. Experience

Craig A. Thompson, MD, MMSc^_*,_*, John E. Jayne, MD, John F. Robb, MD, Bruce J. Friedman, MD, Aaron V. Kaplan, MD, Bruce D. Hettleman, MD, Nathaniel W. Niles, MD, William L. Lombardi, MD

^_* Yale University School of Medicine, New Haven, Connecticut
Dartmouth Hitchcock Medical Center, Dartmouth Medical School, Lebanon, New Hampshire
North Cascade Cardiology–St. Joseph's Hospital, Bellingham, Washington

^_* Reprint requests and correspondence: Dr. Craig A. Thompson, Cardiology Section, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut 06520-8017 (Email: Craig.Thompson{at}Yale.edu).

Objectives: Our purpose was to determine if "Japanese style" technical strategies can be successfully applied in the U.S. practice environment and to better understand the learning curve for chronic total occlusion (CTO) percutaneous coronary intervention (PCI).

Background: Procedural technical success remains the major limiting factor for CTO PCI, and has been unchanged over time.

Methods: Demographic, procedural, and outcome data were collected on 636 consecutive patients between January 2005 and March 2008 having CTO PCI (514 antegrade, 122 retrograde attempts) at 2 U.S. medical centers. Operators were divided into 2 groups: higher CTO volume, retrograde operators (ROs) (>75 total CTO PCI cases and >20 retrograde attempts during the study period) and lower CTO volume, nonretrograde operators (NROs) to evaluate the impact of CTO-specific operator case volume and retrograde techniques on procedural outcomes.

Results: Two operators met the criteria for RO category and 10 were NRO. ROs performed 395 CTO PCI cases (mean total CTO case experience = 197.5, 60 retrograde) and NROs performed 241 CTO PCI cases (mean total CTO case experience = 24.1, <1 retrograde) during the observed timeframe. The overall technical success was 58.9% for NROs and 75.2% for ROs (p < 0.0001). The technical success rate of NROs did not change, but the technical success for the ROs increased to 90% over time (p < 0.0001 for trend, 94.4% for retrograde and 85.7% for antegrade approaches). Observed major adverse events were similar between ROs and NROs.

Conclusions: Complex antegrade and retrograde "Japanese style" PCI approaches can be applied in the U.S. practice environment with high technical success and low adverse event rates. Higher CTO-specific operator case volume is associated with improved technical success rates.

Key Words: angioplasty • stents • chronic total occlusion • retrograde • angiography • collateral

Abbreviations and Acronyms   CABG = coronary bypass surgery   CART = controlled antegrade and retrograde tracking   CTO = chronic total occlusion   NRO = nonretrograde operator   PCI = percutaneous coronary intervention   PTCA = percutaneous transluminal coronary angioplasty   RO = retrograde operator   TIMI = Thrombolysis In Myocardial Infarction

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