Intravascular Ultrasound Comparison of the Retrograde Versus Antegrade Approach to Percutaneous Intervention for Chronic Total Coronary Occlusions

Objectives We sought to evaluate the results of the antegrade versus retrograde chronic total occlusion (CTO) technique with intravascular ultrasound (IVUS) imaging. Background The most common failure mode of CTO interventions remains the inability to successfully cross the occlusion with a guidewire. Recently, the retrograde approach through collateral channels has been introduced to cross complex CTOs. Methods Between October 2002 and April 2008, IVUS was performed in 48 de novo CTO lesions after guidewire crossing +/- pre-dilation with a 1.5- to 2.0-mm balloon. Twenty-three lesions were treated via the antegrade approach (Ante), and 25 lesions were treated via the retrograde approach (Retro). Results Right coronary artery (RCA) CTOs were treated more frequently via the Retro technique. Although the CTO length was much longer in the Retro group (45 +/- 26 mm vs. 18 +/- 9 mm, p < 0.0001), at the end of the procedure Thrombolysis In Myocardial Infarction flow grade 3 was obtained in all patients. There were no significant differences between the 2 groups in minimum stent area and stent expansion. However, the incidence of the composite end point-subintimal wiring, angiographic extravasation, coronary hematoma, or IVUS-detected coronary perforation-was higher in the Retro group (68% vs. 30%, p = 0.01); and the guidewire was more often subintimal in the Retro group (40% vs. 9%, p = 0.02). Conclusions The retrograde approach is a promising option for complex CTO segments, especially long RCA CTOs. Intravascular ultrasound can be a useful tool for the detection of procedure-related vessel damage and subintimal wire tracking. (J Am Coll Cardiol Intv 2009;2:846-54) (C) 2009 by the American College of Cardiology Foundation