Predictors of success in primary retrograde strategy in chronic total occlusion percutaneous coronary intervention: insights from the PROGRESS‐chronic total occlusion registry

Abstract

Background An upfront (primary) retrograde strategy is often used in complex chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Methods We examined the clinical, angiographic characteristics, and procedural outcomes of CTO PCIs that were approached with a primary retrograde strategy in the Prospective Global Registry for the Study of CTO Intervention (PROGRESS‐CTO, NCT02061436). Results Of 10,286 CTO PCIs performed between 2012 and 2022, a primary retrograde strategy was used in 1329 (13%) with an initial technical success of 66%, and a final success of 83%. Patients who underwent successful versus unsuccessful primary retrograde cases had similar characteristics: age (65 ± 10 vs. 65 ± 9, years, p = 0.203), men (83% vs. 87%, p = 0.066), prior PCI (71% vs. 71%, p = 0.809), and prior coronary artery bypass graft surgery (52% vs. 53%, p = 0.682). The PROGRESS‐CTO score (1.3 ± 0.9 vs. 1.6 ± 0.9, p < 0.001), air kerma radiation (3.9 ± 2.8 vs. 3.4 ± 2.6, gray, p = 0.013), and contrast use (294 ± 148 ml vs. 248 ± 128, ml, p < 0.001) were higher in the unsuccessful group, whereas the presence of interventional collaterals (95% vs. 72%, p < 0.001) and Werner collateral connection grade 2 (43% vs. 31%, p < 0.001) were higher in the successful group. On multivariable logistic regression analysis, the only variable associated with a successful primary retrograde strategy was the presence of interventional collaterals: odds ratio: 6.52 (95% confidence intervals; 3.5–12.1, p < 0.001). Conclusion Presence of interventional collaterals is independently associated with higher success rates with a primary retrograde strategy in CTO PCI.

Collateral grading systems in retrograde percutaneous coronary intervention of chronic total occlusions

“…Generally, septal CCs are preferred over epicardial CCs due to a lower risk of perforation and subsequent tamponade 28 . In practice, the majority of CC guidewire tracking is performed through septal CCs (60%–65%), with epicardial CCs (20%–25%) representing a minority 3,29 . We report a modest difference in the percentile distribution of septal and epicardial CCs compared with the previously mentioned cohorts.…”

Impact of proximal cap ambiguity on the procedural techniques and outcomes of chronic total occlusion percutaneous coronary intervention: Insights from the PROGRESS‐CTO Registry

“…Retrograde crossing can provide a solution to proximal cap ambiguity 16 . The retrograde guidewire can be advanced either in the true lumen or in the extraplaque space and cross the occlusion, or help clarify the vessel course and enable antegrade crossing 17 .…”

“…1,3 Retrograde crossing can provide a solution to proximal cap ambiguity. 16 The retrograde guidewire can be advanced either in the true lumen or in the extraplaque space and cross the occlusion, or help clarify the vessel course and enable antegrade crossing. 17 In our study, the retrograde approach was more commonly used as the initial crossing strategy in CTOs with ambiguous proximal cap (24% vs. 7%; p < 0.001) and was also more likely to be the final successful crossing strategy (29% vs. 13%; p < 0.001) compared with CTOs with nonambiguous cap.…”

Applicability of J‐CTO channel score to predict microcatheter tracking during retrograde percutaneous coronary intervention of chronic total occlusions: Insights from the SURFING MICRO registry

“…11,12 However, the overall success is lower in some cases, especially when those collateral connections present complex anatomy with challenging tracking with a guidewire. 13 Therefore, choosing a good and trackable collateral connection is crucial during retrograde CTO-PCI. with a progressively reduced rate of guidewire tracking success according to the score.…”