Retrograde approach for the Recanalizaiton of Coronary CTO: Preliminary Experience of Single Centre Lei Ge, Juying Qian, Xuebo Liu, Qin Qing, Junbo Ge

Retrograde approach for the Recanalizaiton of

Coronary CTO: Preliminary Experience of

Single Centre

Lei Ge, Juying Qian, Xuebo Liu, Qin Qing, Junbo Ge

Department of Cardiology, Zhongshan Hospital,Fudan University

Shanghai Institute of Cardiovascular Diseases

1.The success rate of antegrade approach for the complex CTO recanalization has not dramatically increased. Retrograde techniques may hold great promise.

2.However, this new therapeutic concepts have not been systemically evaluated in our practice environment.

Background

Retrograde approach for the Recanalizaiton of CTO:

Preliminary Experience of Single Centre

Aim of this Study

The purpose of this study is to describe

our experiences of retrograde PCI for

CTO, focusing on its safety and feasibility



1.Patients with coronary CTO who were

attempted with retrograde techniques, either as

the primary strategy (intended initial strategy)

or reattempted way were identified from July

2005 to November 2009.

2.No clinical exclusion criteria were applied.



Study population

1. CC0: no continuous connection between donor and recipient

artery;

2. CC1: continuous, threadlike connection;

3. CC2: continuous, small side branch-like size of the collateral

throughout its course.

Clinical Definition and Methods (1)Angiographic assessment collateral connection

(CC) was based on the classification of

Werner’s:



cardiac death

myocardial infarction (MI)

target vessel revascularization (TVR), either

percutaneous or surgical

Clinical Definition and Methods (2)



MACE was defined as：

Indication of Retrograde approaches



Different of Retrograde Strategies



1. Retrograde approach as the primary strategy

2. Retrograde approach immediately after failed

antegrade attempt

3. Retrograde approach as elective procedure

in patients with previously failed antegrade

attempt

Different of Retrograde Wire TechniquesRetrograde GW

cross CTO

Antegrade GW

cross CTO

Dedicated Devices Needed

Kissing wire technique Yes Yes No

Retrograde wire crossing technique Yes No Short GC and long-shaft

balloons

CART or Reverse CART technique No No Short GC and long-shaft

balloons

Retrograde wire trapping technique Yes No Snare

Reverse Retrograde wire trapping

technique

Yes No Snare

Back-End ballooning + MC reversal Yes No 300cm GW



From July 2005 to November 2009, 42 patients underwent PCI for CTO using the retrograde approach were identified in our center.

Characteristic N (%)

Age (year) 62.8±11.6

Male 41(97.6)

Prior MI 23(54.8)

Prior CABG 2(4.8)

Stable angina 27(64.3)

Unstable angina 15(35.7)

LVEF (%) 57.0±9.9

Mean occlusion duration (months) 36.0±33.6

Previous failed antegrade attempt 10 (23.8)

Baseline clinical characteristics (n=42)




Stump morphology

Tapered 16(38.1)

Blunt 26(61.9)

Side branch/bridging at level of occlusions 33(78.6)

Proximal vessel segment tortuosity 7(16.7)

Calcification 20(47.6)

Ostial location of occlusions 13(31)

Occlusion length (mm) 29.4±12.0

Collateral connection (CC) grade

CC 0 1 (2.4)

CC 1 17 (40.5)

CC 2 24 (57.1)

Angiographic characteristics



Characteristic N (%)Collateral accessed

Septal 39(92.9)Epicardial 2(4.8)

SVG 1(2.4)Collateral crossing wire (n=34)

Runthrough 15 (44.1)Fielder 9 (26.5)Fielder FC 9 (26.5)Fielder XT 1 (2.9)

CTO retrograde crossing wire (n=30)Runthrough 1 (3.3)Whisper 1 (3.3)Fielder 2 (6.6)Fielder FC 4 (13.3)Fielder XT 1 (3.3)Crosswire NT 18 (60.0)Miracle 2 (6.6)Conquest Pro 1 (3.3)

Procedural characteristics (1)



Procedural characteristics (2)


Channel Dilator utilized 11 (26.2)

Tornus utilized 1 (2.4)

Mean contrast volume consumption (ml) 647.6±219.2

Retrograde as primary strategy 590.5±193.4

Retrograde immediately after failed antegrade attempt 809.1±180.0

Retrograde after previous failed antegrade attempt 590.0±237.8



50.00%

26.20%23.80%

71.40% 72.70%70.00%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Retrograde as primarystrategy

Retrograde immediatelyafter failed antegrade

Retrograde after previousfailed antegrade

Utilization percentage

Success rate

Retrograde strategy and successful rates



N=21 N=11 N=10

Flow Diagram of the Procedure Overall success rate: 88.1%




Procedural complication

Collateral dissection 1(2.4)

Collateral perforation 1(2.4)

Tamponade 1(2.4)

Non-target vessel thrombosis 1(2.4)

Dissection of donor vessel 0

Wire or devices entrapment 0

Stent thrombosis 0

In-hosptial MACE 3 (7.1)

Myocardial infarction 3(7.1)

Death 0

TVR 0

Procedural complications and in-hospital outcomes



Summary



1) Overall success rate of recanalization was 88.1%.

2) Retrograde guidewire successful crossed collateral in

34 (80.9%) cases, success rate in this group was

94.1%.

3) In patients with guidewire failure to cross the

collaterals, the success rate of antegrade approach

was 62.5%;

4) In-hospital MACE was 7.1%.

1.Single center, small size observational study with

short-term follow-up is the major limitation of this

report.

2.With regard retrograde approach, a learning curve

clearly exists and its success rate is case volume

dependent. Accordingly, it may not be reasonable that

the results of this study are universally reproduced to

all operators.

Limitations



1.The retrograde approach can be an effective tool for

increasing the success rate of recanalization in the

very complex CTOs.

2.However, we are far from considering the retrograde

approach as a mainstream procedure for all complex

CTO at present.

Clinical Implications



谢谢谢谢

Thank You

2010-3

Documents

Retrograde approach for the Recanalizaiton of Coronary CTO: Preliminary Experience of Single Centre Lei Ge, Juying Qian, Xuebo Liu, Qin Qing, Junbo Ge