Retrograde Chronic Total Occlusion Research Articles

Retrograde Coronary Chronic Total Occlusion Intervention (JR-CTO) Score: From the Japanese CTO-PCI Expert Registry.

Despite the effectiveness of the retrograde approach for chronic total occlusion (CTO) lesions, there are no standardized tools to predict the success of retrograde percutaneous coronary intervention (PCI). The objective of this study was to develop a prediction tool to identify CTO lesions that will achieve successful retrograde PCI. This study evaluated data from 2,374 patients who underwent primary retrograde CTO-PCI and were enrolled in the Japanese CTO-PCI Expert Registry between January 2016 and December 2022 (NCT01889459). All observations were randomly assigned to the derivation and validation cohorts at a 2:1 ratio. The prediction score for guidewire failure in retrograde CTO-PCI was determined by assigning 1 point for each factor and summing all accrued points. The JR-CTO score (moderate-severe calcification, tortuosity, Werner collateral connection grade≤1, and nonseptal collateral channel) demonstrated a C-statistic for guidewire failure of 0.72 (95%CI: 0.67-0.76) and 0.71 (95%CI: 0.64-0.77) in the derivation and validation cohorts, respectively. Patients with lower scores had higher guidewire and technical success rates and decreased guidewire crossing time and procedural time (P< 0.01). The JR-CTO (Japanese Retrograde Chronic Total Occlusion) score, a simple 4-item score that predicts successful guidewire crossing in patients undergoing retrograde CTO-PCI, has the potential to support clinical decision-making for the retrograde approach.

The active pulling technique to solve microcatheter-uncrossable lesions in retrograde chronic total occlusion percutaneous coronary intervention.

It is not uncommon to encounter retrograde microcatheter-uncrossable lesions in retro-recanalization of Chronic Total Occlusion (CTO) cases, existing solutions were time-consuming or complicated to operate. Therefore, the present study aimed to propose and evaluate the feasibility, safety of a novel technique termed Active Pulling retrograde microcatheter crossing Technique (APT) during retrograde CTO percutaneous coronary intervention (PCI). We retrospectively collected retrograde CTO-PCI cases from February 2017 to April 2023, only cases with the retrograde wire successfully crossed the CTO lesion were analyzed. The baseline clinical characteristics, angiographic characteristics, procedural details, and in-hospital major adverse cardiac events (MACEs) were compared. A total of 80 CTO cases were divided into the APT group and the non-APT group according to whether the APT was applied in the procedure. The APT group had a higher rate of device success than the non-APT group (100% vs. 85%, P = 0.013), with shorter duration (5.3 ± 3.8 vs. 18.6 ± 5.9min, P < 0.001) and a smaller number of retrograde microcatheters were used (P < 0.001). In the APT group, the average air kerma radiation exposure was lower (2.7 ± 1.2 vs. 4.3 ± 1.7Gy, P < 0.001), the fluoroscopy time (69.0 ± 15.0 vs. 88.1 ± 18.9min, P < 0.001) and the procedure time (116.2 ± 22.2 vs. 131.6 ± 28.7min, P = 0.009) was shorter than the non-APT group. The technical success rate of both groups reached 100% while the procedure success rate was higher in the APT group than the non-APT group (100% vs. 85%, P = 0.13). The APT is an easy and safe technique that can greatly improve procedural efficiency without adding other instruments, and allows the retrograde microcatheter to quickly crossing the CTO body after successful retrograde wire externalization.

Validation of the J-Channel Score for retrograde channel crossing in the PROGRESS-CTO registry.

Successful collateral channel (CC) crossing is essential for the success of retrograde chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Based on the Japanese CTO PCI expert registry, the J-Channel score was developed to predict CC crossing. We examined the performance of the J-Channel score in patients who underwent retrograde CTO-PCI at 31 centers between 2013-2023 as part of the Prospective Global Registry for the Study of CTO Intervention (PROGRESS-CTO). We observed an association between successful CC crossing and the J-Channel score, its predictive efficacy was modest for both wire and microcatheter crossing.

A New Technique of “Tip-In” for Retrograde Chronic Total Occlusion Revascularization: The Modified Tip-In Technique

A New Technique of “Tip-In” for Retrograde Chronic Total Occlusion Revascularization: The Modified Tip-In Technique

Increased in-hospital complication risk in women undergoing chronic total occlusion recanalization

Abstract Introduction Percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) is a complex procedure that requires advanced operator skills and dedicated devices. Despite increasing success rates of up to 95% in experienced centers, in-hospital complications associated with CTO PCI remain high, and predictors of short-term outcomes and complications are yet scarce. Female sex is often observed to be correlated with in-hospital complications in complex interventions, but current evidence related to CTO PCI is ambiguous and inconclusive. Our aim was to investigate the potential impact of sex on individual and composite in-hospital complications associated with CTO PCI. Methods We prospectively included patients undergoing CTO PCI at our university-affiliated tertiary care center over four years (2018-2021). In this analysis, we compared comprehensive baseline characteristics and angiographic parameters between men and women and estimated their correlation with a composite endpoint of in-hospital complications using adjusted logistic regression analysis. We presented group differences related to individual component in-hospital complications. Results Out of 271 patients undergoing antegrade or retrograde CTO PCI, 222 (81.9%) were men, and 49 (18.9%) were women. Compared with men, women were older (67 ±11 vs. 72±12 years, P=.005) and had less prior PCI (65.8% vs. 44.9%, P=.006). Both groups had comparable angiographic complexity. Overall MACCE was 2.6%, and any in-hospital complication occurred in 8 women (16.3%) and 15 men (6.8%). Univariate analysis showed that sex, J-CTO score, and proximal cap ambiguity were correlated with the primary composite endpoint. By adjusted multivariate analysis, sex was independently associated with any in-hospital complication (OR=.334; CI .129 to .864; P=.024). The results were numerically driven by major bleeding, acute kidney injury, and MACCE. Conclusion Our findings suggest that women undergoing CTO PCI are at an increased risk of any in-hospital complication, regardless of clinical severity. Further studies are needed to confirm this finding and explain potential gender disparities in patients undergoing CTO PCI.Clinical and angiography characteristicsIn-hospital complications

Accurate Prediction of Retrograde Collateral Channel Crossing in Coronary Artery Chronic Total Occlusion Intervention

Successful collateral channel (CC) crossing is an essential step in retrograde chronic total occlusion (CTO) percutaneous coronary interventions (PCI). We previously developed a dedicated CC score based on CC size and tortuosity to facilitate target CC selection. Validation and comparison to other scoring systems were lacking. Thus, the aims of this study were to 1) validate the CC score in a larger independent cohort, and 2) compare its accuracy and clinical usefulness with the J-channel score. All coronary CTO PCIs attempted by experienced high-volume operators from January, 2017 to December, 2021 were enrolled. The CC and J-channel scores were calculated for all attempted CCs with bi-plane high-resolution cine angiography images. CC crossing success was defined as guidewire reaching the distal true lumen retrogradely. In total, 502 patients who received CTO PCI were included. The retrograde approach was utilized in 244 target CTOs, and a total of 329 CCs were attempted. The overall CC crossing rate was 67.8% (223/329) and final technical success rate 92.2% (225/244). The average CC score was 2.0 and average J-channel score was 0.71. The sensitivity and specificity of successful CC crossing with the CC score ≥2 were 81.2%, and 84.0%, respectively. Comparison between the CC score (area under the curve [AUC] 0.87; 95% confidence interval [CI] 0.83-0.90) and the J-channel score (AUC 0.61; 95% CI 0.55-0.67) demonstrated superior predictive performance of the CC score (p <0.001). The CC score was an easy-to-use and accurate tool for the prediction of successful CC crossing in retrograde CTO PCI. The CC score can help operators select the ideal target CC, thereby facilitating final procedural success.

Retrograde Approach via Ipsilateral Septal Collateral Channel in Percutaneous Coronary Intervention for Coronary Chronic Total Occlusion: A Single-Center Experience.

The septal collateral channel (CC) is the preferred channel in retrograde percutaneous coronary intervention (PCI) for chronic total occlusion (CTO). However, reports on the utilization of the ipsilateral septal CC are limited. To evaluate the feasibility and safety of the ipsilateral septal CC in retrograde CTO PCI. Twenty-five patients with successful wire CC tracking via the ipsilateral septal CC in retrograde CTO PCI were retrospectively analyzed. All procedures were performed by experienced CTO operators. Procedures were divided into the left descending coronary artery (LAD)-septal-LAD group and the LAD-septal-left circumflex coronary artery (LCX) group. Procedural complications and in-hospital outcomes were ascertained. Both groups were similar with respect to risk factors and angiographic characteristics of the CTO, except for the collateral tortuosity (86.7% vs 20%, p=0.002). The success rate of microcatheter CC tracking was 96%. Both technical success and procedural success rates were 92%. Procedural complications were found in one case (septal perforation, 4%), which happened in the LAD-septal-LAD group (p=0.250). One postoperative adverse event (Q-wave myocardial infarction, 4%) was observed before discharge. The retrograde approach via the ipsilateral septal CC was feasible, with high success rates and acceptable complications, in the hands of experienced operators.

Retrograde percutaneous coronary intervention of chronic total occlusion via discontinuous septal channels.

The study aims to investigate the safety and feasibility of retrograde CTO intervention via collateral connection grade 0 (CC-0) septal channel and to identify predictors of collateral tracking failure. Guidewire crossing a collateral channel is a critical step for successful retrograde percutaneous coronary intervention (PCI) of chronic total occlusion (CTO). Retrograde PCI was attempted in 122 cases of CTO with CC-0 septal collaterals from December 2018 to May 2021. A hydrophilic polymer coating guidewire was used for crossing all intended CC-0 collaterals. A multivariable logistic regression analysis was performed to identify the predictors of guidewire tracking failure via the CC-0 collaterals. Successful guidewire tracking via CC-0 septal channel was achieved in 98 (80.3%) of 122 cases. The independent predictors of CC-0 septal channel guidewire tracking failure included well-developed non-septal collateral (OR: 5.297, 95% CI: 1.107-25.353, p = 0.037) and the ratio length of posterior descending artery (PDA) versus the distance of PDA ostium to cardiac apex ≤2/3 (OR: 3.970, 95% CI: 1.454-10.835, p = 0.007). Collateral perforation, target vessel perforation, and cardiac tamponade occurred in 5 (4.1%), 3 (2.5%), and 6 (4.9%) cases, respectively. There were no complications requiring emergency cardiac surgery or revascularization of nontarget vessel. Retrograde PCI via CC-0 septal channels with a hydrophilic polymer-coated guidewire is feasible and safe in patients with CTO. Well-developed nonseptal collaterals and short PDA length influence the procedure success and the risk of guidewire tracking failure via CC-0 septal channels.

B-20 | Assessment of the ERCTO Score for Predicting Success in Retrograde Chronic Total Occlusion Percutaneous Coronary Interventions in the PROGRESS-CTO Registry

The retrograde strategy is a common approach used in complex chronic total occlusion (CTO) percutaneous coronary intervention (PCI). The ERCTO Retrograde score is a tool that aims to predict the likelihood of technical success for retrograde CTO PCI procedures by evaluating five parameters: calcification, distal opacification, proximal tortuosity, collateral connection classification, and operator volume. We evaluated the performance of the ERCTO Retrograde score using data from 2,341 patients enrolled in the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO) at 35 centers between 2013 and 2023. Retrograde CTO PCI was the primary crossing strategy in 871 cases (37.2%) and a secondary crossing strategy in 1,467 cases (62.8%). Technical success was achieved in 1,810 cases (77.3%). The technical success rate was higher for primary retrograde cases compared with secondary retrograde cases (79.8% vs 75.9%; p=0.031). The ERCTO Retrograde score was positively associated with the likelihood of procedural success. The c-statistic of the ERCTO retrograde score was 0.636 (95% confidence intervals [CI]: 0.610 – 0.662) for all cases and 0.651 (95% CI: 0.607 – 0.695) for primary retrograde cases. The ERCTO Retrograde score has modest predictive capacity for technical success in retrograde CTO PCI.

TCTAP C-101 Rotational Atherectomy in False Lumen Rescued by Retrograde Chronic Total Occlusion Techniques

TCTAP C-101 Rotational Atherectomy in False Lumen Rescued by Retrograde Chronic Total Occlusion Techniques

Drug-eluting balloon angioplasty improves the distal run-off in retrograde chronic total occlusion revascularization

Drug-eluting balloon angioplasty improves the distal run-off in retrograde chronic total occlusion revascularization

Role of collateral circulation in maintaining and restoring the left ventricular function and modern methods for its assessment

The coronary blood flow plays an important role in protecting the myocardium from ischemia and maintaining the cardiomyocyte function in the event of occlusion of one of the epicardial arteries. It also has a potential for restoring the contractile function during subsequent myocardial revascularization, which requires its more detailed research. Most methods for assessing coronary collaterals are carried out to define the potential of their use for Retrograde chronic total occlusion recanalization. Currently, the most widely used method for assessing collateral blood flow is angiography, which, despite its relative simplicity and good knowledge, has following limitations: invasiveness, operator dependence, limited visualization, etc. At the same time, a number of other diagnostic methods can also be used to assess collateral flow. This review article is aimed at a detailed study of modern invasive and non-invasive methods for assessing the development and function of collateral vessels.

Safety and Feasibility of Rotational Atherectomy for Retrograde Recanalization of Chronically Occluded Coronary Arteries.

ObjectiveTo evaluate the safety and feasibility of rotational atherectomy (RA) in retrograde chronic total occlusion percutaneous coronary intervention (CTO-PCI) by analyzing immediate and long-term outcomes.BackgroundRecent evidence supports the safety and feasibility of RA in CTO-PCI. However, few studies have focused on the use of RA in a retrograde approach to percutaneous revascularization of chronic total occlusion (CTO) lesions and information on long-term outcomes is lacking.MethodsA total of 329 patients who underwent retrograde CTO-PCI, out of 1496 consecutive CTO-PCI patients from April 2017 to July 2020, were retrospectively recruited from the 2nd Cardiology Department of the Guangdong Provincial People's Hospital. 16 patients underwent RA (RA group) whilst 313 did not (non-RA group).ResultsTechnical (87.5% vs. 87.5) and procedural (85.9% vs. 87.5) success rates were similar between both groups. There was no difference concerning major procedural complications between groups (12.5% vs. 19.2%; p > 0.75). No in-hospital MACCEs was recorded in the RA group while there were eight MACCEs in the non-RA group (p > 0.99). In the RA group, 2 cases recorded perforation (1 target vessel perforation case and 1 branch vessel perforation), and 55 cases of vessel perforations/dissections were recorded in non-RA group including 18 target vessel perforations, 2 branch vessel perforations, 35 collateral vessel perforations (one patient died from cardiac tamponade). No difference was found in terms of the perforation rate between the two groups (p > 0.99). Over a mean follow-up period of 26.47 ± 14.46 months, use of RA in retrograde CTO-PCI did not result in an increased mortality rate [hazard ratio (HR) 1.58, 95% confidence interval (CI), 0.31–8.21, p = 0.65], major adverse cardiac and cerebral events (HR 0.99, 95% CI 0.35–2.79, p = 0.99) or overall rehospitalization rate (HR 1.27, 95% CI 0.44–3.67, p = 0.67). Adjusted Kaplan–Meier curves according to Cox regression model suggested several predictors influencing the all-cause mortality, cardiovascular mortality, MACCEs, stroke rate, non-fatal myocardial infarction, target vessel recanalization rate and rehospitalization rate in the comparison.ConclusionsOur study demonstrates that the in-hospital outcomes and long-term follow up events were the same between RA and non-RA retrograde CTO-PCI patients. RA offered an option for skillful operators in difficult cases when the lesion was severely calcified in retrograde CTO-PCI.

Retrograde Chronic Total Occlusion Percutaneous Coronary Interventions: Predictors of Procedural Success From the ERCTO Registry.

The aim of this study was to identify independent predictors of procedural success after retrograde chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Retrograde CTO PCI is an established technique, but predictors of success remain poorly understood. A multivariable logistic regression model was used to analyze potentially important demographic, clinical, anatomical, and technical aspects of retrograde CTO PCI cases uploaded to the multicenter European CTO (ERCTO) Club Registry. In calendar years 2018 and 2019, 2,364 retrograde CTO PCI cases constituted the primary analysis cohort. Aprimary retrograde strategy was used in 1,953 cases (82.6%), and an initial antegrade approach was converted to retrograde in 411 cases (17.4%). Procedural success was achieved in 1,820 cases (77.0%) and was more likely to occur after a primary retrograde attempt versus conversion from an initial antegrade approach (80.9% vs 58.4%; P< 0.0001). After multivariable analysis, an absence of lesion calcification (OR: 1.86; 95%CI: 1.37-2.51; P< 0.0001), a higher degree of distal vessel opacification (OR: 2.47; 95%CI: 1.72-3.55; P< 0.0001), little or no proximal target vessel tortuosity (OR: 1.84; 95%CI: 1.28-2.64; P=0.001), Werner collateral connection CC1 (OR: 4.87; 95%CI: 2.90-8.19; P< 0.0001) or CC2 (OR: 5.33; 95%CI: 3.02-9.42; P< 0.0001), and the top tertile of operator volume (>120 cases over 2 years) (OR: 1.88; 95%CI: 1.26-2.79; P=0.002) were associated with the greatest chance of achieving angiographic success. Less calcification with good distal vessel opacification, little or absent proximal vessel tortuosity, and visible collateral connections, along with high-volume operator status, were all independently predictive of angiographically successful retrograde CTO PCI.

Chronic Total Occlusion Anatomy and Characteristics of Coronary Collaterals and Angiographic Features Predicting the Success of Chronic Total Occlusion Intervention

Background and Objective: Angiographic assessment of chronic total occlusion (CTO) anatomy and collateral characteristics of coronary arteries are necessary for CTO intervention. Materials and Methods: This was a hospital-based observational study of 100 coronary angiograms (CAG) with CTOs. CTO anatomy and collateral characteristics of coronary arteries were studied for predicting anterograde and retrograde CTO intervention. Results: Right coronary artery (RCA) CTO was the most common (62%), followed by left anterior descending (LAD). More than two-thirds of RCA and LAD CTO lesions were >20 mm and half were in mid-segment. Left circumflex artery (LCX) and RCA lesions were more frequently calcified. LAD CTOs often had blunt stump; LCX CTOs frequently had bending >45°. The mean J-CTO score was lowest in RCA CTOs (2.0 ± 1.19). There were 10 different types of collaterals in RCA CTOs, 8 in LAD CTOs, and only 4 in LCX CTOs. The most common RCA CTOs collateral was LAD septal to the right posterior descending artery (RPDA) (69.4%) and in LAD CTOs, the most common was septal collaterals from the RPDA to LAD (40.9%). RCA CTOs had a higher percentage of septal collaterals, less tortuosity, and favorable entry and exit angle when compared with other two arteries. Conclusion: RCA CTOs were the most common. Angiographic features in CTO lesions vary among three major coronary arteries. The RCA CTOs had lesser mean J-CTO score, more number of septal collaterals, less tortuous collaterals, and favorable entry and exit angle. RCA CTOs were better accessible for anterograde and retrograde intervention.

Four-Year Follow-Up of Absorb BVS Compared to Xience EES in Daily Clinical Practice Shows Continued Accrual of Events

Percutaneous revascularization of chronic total occlusions (CTOs) is known for the high technical complexity. Considering the constant increase in CTO procedures, subsequent peri-procedural complications will rise too, thus they need to be promptly recognized and evaluated for their potential risk of clinical sequelae. We report the case of a newly described complication during trans-septal retrograde CTO intervention: a septal collateral artery dissection due to endothelial avulsion.

Retrograde chronic total occlusion percutaneous coronary intervention using single catheter: A single centre registry

ObjectivesTo analyse the feasibility, safety and procedural outcomes of percutaneous coronary intervention (PCI) for chronic total occlusions (CTO) through retrograde approach using single catheter. MethodsOur study was a retrospective observational study that enrolled patients who underwent retrograde CTO PCI using a single catheter between June 2016 and February 2020. Clinical success was defined as successful completion of CTO PCI without associated in-hospital major clinical complications like death, myocardial infarction, stroke or urgent revascularisation. Technical success was defined as successful completion of CTO PCI using single catheter and minimum diameter stenosis of <30% with thrombolysis in myocardial infarction (TIMI) flow grade 3, without significant side branch occlusion, flow-limiting dissection, distal embolization, or angiographic thrombus. ResultsTotally 102 patients underwent retrograde CTO PCI during the study period. Out of which, 15 cases were attempted using single catheter. Mean age of the population was 59.1 ± 8.9 years (males: 86.7%) and the left ventricular ejection fraction (LVEF) was (61% ± 9.1%). Mean number of diseased arteries was 2.1 ± 0.7, length of the CTO was 25.5 ± 7.4 mm and J-CTO score was 2.3 ± 0.7. We achieved a technical success rate of 73.3% using single catheter, and the overall clinical success (Including single catheter and ping pong) was obtained in 86.7% cases. One patient (6.7%) developed cardiac tamponade and none of study population required dialysis for contrast induced acute kidney injury (CI-AKI) ConclusionsRetrograde CTO PCI using single catheter is a technically challenging procedure when compared with other CTO PCI. Our study demonstrated acceptable outcomes which is comparable to other antegrade and retrograde CTO PCI registries.

Comparison of Vascular Closure Device Strategies for Transfemoral Transcatheter Aortic Valve Replacement and Associated Vascular Complications

Percutaneous revascularization of chronic total occlusions (CTOs) is known for the high technical complexity. Considering the constant increase in CTO procedures, subsequent peri-procedural complications will rise too, thus they need to be promptly recognized and evaluated for their potential risk of clinical sequelae. We report the case of a newly described complication during trans-septal retrograde CTO intervention: a septal collateral artery dissection due to endothelial avulsion.

Impact of Lesion Complexity and Stent Characteristics on One-Year Clinical Outcomes: A Sub-Analysis of the Recre8 Trial

Percutaneous revascularization of chronic total occlusions (CTOs) is known for the high technical complexity. Considering the constant increase in CTO procedures, subsequent peri-procedural complications will rise too, thus they need to be promptly recognized and evaluated for their potential risk of clinical sequelae. We report the case of a newly described complication during trans-septal retrograde CTO intervention: a septal collateral artery dissection due to endothelial avulsion.

TCTAP C-046 Retrograde Chronic Total Occlusion Intervention in Right Coronary Artery

TCTAP C-046 Retrograde Chronic Total Occlusion Intervention in Right Coronary Artery