Outcomes with retrograde versus antegrade chronic total occlusion revascularization

Abstract

Objectives The aim of the study was to evaluate the outcomes of retrograde versus antegrade approach in chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Background The retrograde approach has increased the success rate of CTO PCI but has been associated with a higher risk for complications. Methods We conducted a meta‐analysis of studies published between 2000 and August 2019 comparing the in‐hospital and long‐term outcomes with retrograde versus antegrade CTO PCI. Results Twelve observational studies (10,240 patients) met our inclusion criteria (retrograde approach 2,789 patients, antegrade approach 7,451 patients). Lesions treated with the retrograde approach had higher J‐CTO score (2.8 vs. 1.9, p < .001). Retrograde CTO PCI was associated with a lower success rate (80.9% vs. 87.4%, p < .001). Both approaches had similar in‐hospital mortality, urgent revascularization, and cerebrovascular events. Retrograde CTO PCI was associated with higher risk of in‐hospital myocardial infarction (MI; odds ratio [OR] 2.37, 95% confidence intervals [CI] 1.7, 3.32, p < .001), urgent pericardiocentesis (OR 2.53, 95% CI 1.41–4.51, p = .002), and contrast‐induced nephropathy (OR 2.12, 95% CI 1.47–3.08; p < .001). During a mean follow‐up of 48 ± 31 months retrograde crossing had similar mortality (OR 1.79, 95% CI 0.84–3.81, p = .13), but a higher incidence of MI (OR 2.07, 95% CI 1.1–3.88, p = .02), target vessel revascularization (OR 1.92, 95% CI 1.49–2.46, p < .001), and target lesion revascularization (OR 2.08, 95% CI 1.33–3.28, p = .001). Conclusions Compared with antegrade CTO PCI, retrograde CTO PCI is performed in more complex lesions and is associated with a higher risk for acute and long‐term adverse events.

With great power comes great responsibility: When and how to use the retrograde approach to chronic total occlusion interventions

“…2 All cases were performed by expert CTO operators. 2 Similar to prior studies, 3,4 patients in the retrograde CTO PCI group had more complex lesions with longer lesion length, blunt proximal cap, severe tortuosity and calcification, and higher Japanese CTO score. They also had longer procedure duration, higher contrast and radiation dose, lower technical and procedural success, and higher risk of periprocedural complications, including mortality.…”

Mastering retrograde coronary chronic total occlusion intervention in 2021

“…The retrograde approach carries a higher risk of complications compared with antegrade-only crossing. 37 The retrograde CTO PCI were longer, associated with higher contrast volume and fluoroscopy time, and higher risk of complications, such as pericardiocentesis, periprocedural myocardial infarction and contrast-induced nephropathy, 38 in a meta-analysis with more than 7,000 patients. In the same study, retrograde CTO PCI was associated with worse long-term outcomes, including target lesion revascularization, target vessel revascularization, and myocardial infarction, compared with antegrade over four years.…”

The Canadian Contribution to Science, Techniques, Technology, and Education in Chronic Total Occlusion Percutaneous Coronary Intervention

“…From an era of dabbling with poorly selected guidewires bent with large radius curves, without contra-lateral guidance, and poor expected (and observed) results, we have successfully moved to an era where up-to-date standardized techniques and approaches are taught, encouraged, and available in most hospitals across the country. Canadian authors have contributed to the rapid expansion of information sources available to learn the hybrid approach, from consensus statements, 32,33 international research collaborations, [34][35][36][37][38][39][40][41][42] review articles, [43][44][45][46][47][48][49][50][51][52][53][54][55] editorial comments, 26,[56][57][58][59][60][61][62][63][64][65] case series or reports, [66][67][68][69][70][71][72][73][74] dedicated textbooks, 75 and as faculty in large dedicated CTO PCI conferences across the world. All sources of...…”