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
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Figure 1 Basic Concept of Retrograde Approach
(A) Retrograde wire crossing technique: retrograde wiring is performed with a dedicated slippery guidewire with microcatheter from the collateral-supplying vessel into the distal vessel. Then, the retrograde guidewire is steered proximally, ideally to the antegrade guiding catheter. (B) Kissing wire technique: the retrograde guidewire can also be used as a marker when crossing the chronic total occlusion lesion from the antegrade direction. Finally, both the antegrade and retrograde guidewires link up with each other; and the antegrade guidewire is advanced to the distal vessel. Figure is courtesy of Dr. M. Ochiai.
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Figure 2 Representative IVUS Images
(A) Subintimal wiring was defined as the intravascular ultrasound (IVUS) catheter located in the subintimal space (arrowheads, absence of arterial wall 3 layers) (note the collapsed true lumen at 2 o'clock). (B) The IVUS-detected coronary perforation was defined as blood speckle outside the vessel (arrowheads) and/or tear of the adventitia despite a lack of angiographic extravasation. (C) Coronary hematoma was defined as an accumulation of blood (arrowheads) recognized typically as a crescent-shaped homogeneous hyperechoic structure with straightening of the internal elastic membrane.
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Figure 3 Influence of CTO Length on Technique Selection and Subintimal Wiring
The retrograde technique was selected more frequently with increasing chronic total occlusion (CTO) length. The frequency of subintimal wiring also tended to increase with increasing CTO length. In the longest CTO quartile, the subintimal wiring was observed in 50% of the CTO lesions. Ante = antegrade approach; Retro = retrograde approach.
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Figure 4 Comparison of Ante Versus Retro
The retrograde approach (Retro) group had significantly higher incidence of composite end point—defined as a combination of subintimal wiring, angiographic extravasation, coronary hematoma (intramural or extramural), or intravascular ultrasound (IVUS)-detected coronary perforation (68% vs. 30%, p = 0.01). Ante = antegrade approach.
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