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Intravascular Ultrasound Comparison of the Retrograde Versus Antegrade Approach to Percutaneous Intervention for Chronic Total Coronary Occlusions

Kenichi Tsujita, MD, PhD^_*, Akiko Maehara, MD^_*,_*, Gary S. Mintz, MD^_*, Takashi Kubo, MD, PhD^_*, Hiroshi Doi, MD, PhD^_*, Alexandra J. Lansky, MD^_*, Gregg W. Stone, MD^_*, Jeffrey W. Moses, MD^_*, Martin B. Leon, MD^_*, Masahiko Ochiai, MD, PhD

^_* Cardiovascular Research Foundation and Columbia University Medical Center, New York, New York
Showa University Northern Yokohama Hospital, Yokohama, Japan

^_* Reprint requests and correspondence: Dr. Akiko Maehara, Cardiovascular Research Foundation/Columbia University Medical Center, 111E 59th Street, New York, New York 10022 (Email: amaehara{at}crf.org).

Objectives: We sought to evaluate the results of the antegrade versus retrograde chronic total occlusion (CTO) technique with intravascular ultrasound (IVUS) imaging.

Background: The most common failure mode of CTO interventions remains the inability to successfully cross the occlusion with a guidewire. Recently, the retrograde approach through collateral channels has been introduced to cross complex CTOs.

Methods: Between October 2002 and April 2008, IVUS was performed in 48 de novo CTO lesions after guidewire crossing ± pre-dilation with a 1.5- to 2.0-mm balloon. Twenty-three lesions were treated via the antegrade approach (Ante), and 25 lesions were treated via the retrograde approach (Retro).

Results: Right coronary artery (RCA) CTOs were treated more frequently via the Retro technique. Although the CTO length was much longer in the Retro group (45 ± 26 mm vs. 18 ± 9 mm, p < 0.0001), at the end of the procedure Thrombolysis In Myocardial Infarction flow grade 3 was obtained in all patients. There were no significant differences between the 2 groups in minimum stent area and stent expansion. However, the incidence of the composite end point—subintimal wiring, angiographic extravasation, coronary hematoma, or IVUS-detected coronary perforation—was higher in the Retro group (68% vs. 30%, p = 0.01); and the guidewire was more often subintimal in the Retro group (40% vs. 9%, p = 0.02).

Conclusions: The retrograde approach is a promising option for complex CTO segments, especially long RCA CTOs. Intravascular ultrasound can be a useful tool for the detection of procedure-related vessel damage and subintimal wire tracking.

Key Words: chronic total coronary occlusion • imaging • retrograde approach • ultrasonics

Abbreviations and Acronyms   Ante = antegrade approach   CART = controlled antegrade and retrograde subintimal tracking   CI = confidence interval   CSA = cross-sectional area   CTO = chronic total (coronary) occlusion   EEM = external elastic membrane   IVUS = intravascular ultrasound   MSA = minimum stent area   OR = odds ratio   PCI = percutaneous coronary intervention   Retro = retrograde approach   TIMI = Thrombolysis In Myocardial Infarction