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The Retrograde Technique for Recanalization of Chronic Total Occlusions

A Step-by-Step Approach

Dominique Joyal, MD^_*, Craig A. Thompson, MD, J. Aaron Grantham, MD^||, Christopher E.H. Buller, MD, Stéphane Rinfret, MD, SM^,_*

^_* Jewish General Hospital, McGill University, Montreal, Quebec, Canada
Institut Universitaire de Cardiologie et de Pneumologie de Québec, (Quebec Heart and Lung Institute), Laval University, Quebec City, Quebec, Canada
St-Michael's Hospital, Toronto, Ontario, Canada
Yale University School of Medicine, New Haven, Connecticut
^|| Saint Luke Hospital, Kansas City, Missouri

^_* Reprint requests and correspondence: Dr. Stéphane Rinfret, Clinical and Interventional Cardiology, Multidisciplinary Cardiology Department, Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart and Lung Institute), 2725, chemin Ste-Foy, Quebec City, Quebec G1V 4G5, Canada (Email: stephane.rinfret{at}criucpq.ulaval.ca).

Chronic total occlusion recanalization still represents the final frontier in percutaneous coronary intervention. Retrograde chronic total occlusion recanalization has recently become an essential complement to the classical antegrade approach. In experienced hands, the retrograde technique currently has a high success rate with a low complication profile, despite frequent utilization in the most anatomically and clinically complex patients. Since its initial description, important changes have occurred that make the technique faster and more successful. We propose a step-by-step approach of the technique as practiced at experienced centers in North America. Because the technique can vary substantially, we describe the different alternatives to each step and offer what we perceived to be the most efficient techniques.

Key Words: chronic total occlusion • percutaneous coronary interventions

Abbreviations and Acronyms   CART = controlled antegrade and retrograde subintimal tracking   CC = collateral channel   CTO = chronic total occlusion   IVUS = intravascular ultrasound   LAD = left anterior descending coronary artery   LCX = left circumflex   PCI = percutaneous coronary intervention   PDA = posterior descending artery   PL = posterolateral   RAO = right anterior oblique   RCA = right coronary artery