A unique complication of the retrograde approach in angioplasty for chronic total occlusion of the coronary artery

The retrograde approach for chronic total occlusion of coronary arteries is a new treatment strategy, although its attendant complications have not yet been fully appreciated. We report a case of isolated left ventricular cardiac tamponade caused by guidewire‐induced perforation of the septal branch during the retrograde approach, which was subsequently diagnosed by computed tomography (CT) and which required surgical drainage. Guidewire‐induced perforation of the septal branch was successfully treated by autologous subcutaneous tissue embolization of the perforated coronary artery. This is the first case of its kind to date. © 2008 Wiley‐Liss, Inc.     

The retrograde approach to coronary artery chronic total occlusions: a practical approach

The retrograde approach has revolutionized the treatment of chronic total occlusions. Several retrograde techniques have recently been described. In this article, we present a practical review with step-by-step instructions on the indications for retrograde interventions, equipment and retrograde channel selection, and techniques for retrograde crossing and treatment of chronic total occlusions.     

A new technique for shortening a guiding catheter during retrograde recanalization of a chronic total occlusion

This report introduces successful retrograde angioplasty of chronic total occlusion with a long collateral channel using a new technique of shortening the guiding catheter. With this method, we secured the lengths of the guidewire and the microcatheter for retrograde intervention without sacrificing the position of the tracked guidewire. © 2010 Wiley‐Liss, Inc.     

Different strategies of retrograde approach in coronary angioplasty for chronic total occlusion

Background:

Retrograde approach through the collateral channels has been recently proposed and has the potential to improve the success rate of percutaneous coronary intervention (PCI) in chronic total occlusion (CTO) lesions of the coronary arteries.

Methods:

The author performed retrograde approach for CTO lesions in 45 patients from January 2006 to January 2007 at different medical institutions worldwide. The details of the techniques were examined retrospectively.

Results:

The septal branch route was used in 93% of the cases. The author classified the strategies into six types after the successful crossing of a guidewire into the target artery distal to the CTO lesion through the collateral channels. Among them, “Just landmark,” “Controlled antegrade and retrograde subintimal tracking,” and “Proximal true lumen puncture” strategies were used most frequently (32, 27, and 30%, respectively). The retrograde guidewires could be successfully passed distal to the CTO lesion in 37 patients (82%), among them the final PCI success was achieved in 31 patients, yielding the PCI success by pure retrograde approach of 69%. The final success rate among 45 patients including 42 patients with previous failed attempts was 84% (38 patients). There were no serious complications related to the retrograde approach.

Conclusions:

Retrograde approach with different strategies, mainly through septal arteries, can provide a high success rate with PCI, as shown in 83% of patients with previous failed attempts at traditional PCI for CTO lesions, with there being no serious complications. More experience of this technique and its refinement are required for further improvement of PCI techniques for CTO lesions. © 2008 Wiley‐Liss, Inc.     

A new retrograde wiring technique for chronic total occlusion

To improve the success rate of percutaneous coronary intervention for coronary chronic total occlusion (CTO), different strategies of retrograde approach were introduced in recent years. The aim of this report is to describe a new retrograde wiring technique for CTO, the “Bridge or Rendezvous method.” This new technique saves time, reduces cost, as well as reduces procedure‐related complications. © 2009 Wiley‐Liss, Inc.     

Percutaneous coronary intervention for a right coronary artery stent occlusion using retrograde delivery of a sirolimus‐eluting stent via a septal perforator

In percutaneous coronary intervention for chronic total occlusion (CTO), the retrograde approach is an advanced technique. To improve the long‐term patency rate, stent implantation is necessary for CTO, however, antegrade stent delivery to the lesion is contraindicated in cases where there is an anomalous origin or deviation of the coronary artery, or the edge of a previously implanted stent extends into the aorta. We report a successful case of retrograde stent implantation via a septal perforator in a patient with marked deviation of the RCA origin. In this case, antegrade stent implantation was difficult because antegrade catheter insertion carried a risk of crush deformation of an ostial stent. © 2009 Wiley‐Liss, Inc.     

Percutaneous coronary intervention of chronic total occlusion in a left anterior descending coronary artery using an ipsilateral intraseptal bridging collateral tracking technique

As one of the great breakthrough techniques in the percutaneous coronary intervention (PCI) for the chronic total occlusions of coronary arteries, the controlled antegrade and retrograde subintimal tracking, so called the “CART” technique, has been developed. We present a first case in whom CTO of the mid LAD coronary artery was well‐recanalized using the CART technique via the ipsilateral intraseptal bridging collaterals in the PCI. © 2010 Wiley‐Liss, Inc.     

Drug-eluting stent-supported percutaneous coronary intervention for chronic total coronary occlusion.

OBJECTIVES: This study sought to determine the clinical and angiographic outcomes after drug-eluting stent (DES)-supported percutaneous coronary intervention (PCI) for chronic total coronary occlusion (CTO). BACKGROUND: There are few data about the efficacy of DES-supported PCI for CTO. METHODS: All consecutive patients who had a sirolimus-eluting stent or a paclitaxel-eluting stent implanted for CTO from December 2003 to December 2004 were analyzed. Clinical and angiographic outcomes of patients treated with DES were compared with a case-matched control group of patients treated with bare metal stents (BMS) in the 12 months before the routine use of DES. RESULTS: Successful DES-supported PCI was performed in 92 patients and 104 CTO. The case-matched control group consisted of 26 patients and 27 CTO successfully treated with BMS. There were no differences between groups in baseline clinical and angiographic characteristics. Stent length in the DES group was higher as compared with that of BMS group (51+/-28 mm vs. 40+/-19 mm, P=0.073). The 6-month major adverse cardiac event (MACE) rate was lower in the DES group as compared with that of BMS group (9.8% vs. 23%, P=0.072). The angiographic follow-rate was 80% in the DES group and 81% in the BMS group. The 6-month restenosis rate was 19% in the DES group and 45% in the BMS group (P<0.001). By multivariate analysis, it was found that in the DES group, the only predictors of restenosis were stented segment length (OR 1.031, 95% CI 1.01-1.06, P=0.009) and a target vessel reference diameter<2.5 mm (OR 6.48, 95% CI 1.51-27.83, P=0.012), while the only predictor of MACE was stent length (OR 1.04, 95% CI 1.01-1.08, P=0.006). CONCLUSIONS: DES implantation for CTO decreases the risk of mid-term restenosis and MACE. Small vessels and diffuse disease requiring the implantation of multiple stents and very long stents for full coverage of the target lesion are still associated with a relatively high risk of restenosis.     

Coronary septal collaterals as an access for the retrograde approach in the percutaneous treatment of coronary chronic total occlusions.

OBJECTIVES: To investigate the feasibility and safety of the percutaneous dilatation of coronary septal collaterals and to allow its use as an access for retrograde approach to percutaneous coronary intervention (PCI) of coronary chronic total occlusions (CTOs). BACKGROUND: Despite improvements in percutaneous techniques and materials, CTO recanalization success rate is still suboptimal. The retrograde approach allows to significantly increase this success rate. However, its application via a bypass graft or epicardial collateral can potentially result in severe complications. A safer retrograde access is desired and would allow broadening the application of the retrograde approach in the percutaneous treatment of CTOs. METHODS: After a failed antegrade CTO recanalization attempt, a retrograde approach via septal collaterals was tried in 21 patients (19 males, 2 females). The septal collateral was accessed via the contralateral patent coronary artery and was crossed with a hydrophilic floppy wire. After successful wire crossing of the septal collateral, sequential low pressure dilatation was performed with a 1.25 or 1.5 mm balloon to allow the delivery of a balloon catheter up to the distal CTO site. RESULTS: Successful wire crossing and balloon dilatation of septal collaterals was achieved in 19 cases and in 17 cases, respectively. Postdilatation septal collateral diameter increased significantly reaching a mean diameter of 1.46 +/- 0.38 mm. Retrograde CTO recanalization was successfully performed in 71% of the cases. No major complications occurred. CONCLUSIONS: Coronary septal collaterals can be used as an access for the retrograde approach in the percutaneous treatment of CTOs.     

A comparison of the transradial and the transfemoral approach in chronic total occlusion percutaneous coronary intervention

Background: Transradial coronary intervention is a safe and effective method of percutaneous revascularization. Furthermore, the indications for transradial percutaneous coronary intervention (PCI) are expanding. However, there is limited data on the efficacy and the safety of the transradial approach for chronic total occlusion (CTO) PCI. Methods: We examined 468 patients who underwent CTO PCI between January 2003 and December 2005, and compared the radial (318 patients) and the femoral (150 patients) approach. Results: Baseline demographics, lesion location, and the vessel treated were similar in both groups. Angiographic success was 82% in radial versus 86% in femoral group, P = 0.28, similar in both groups. Total fluoroscopy time (24.49 ± 13.18 vs. 24.07 ± 14.12 min, P = 0.36), total procedure time (54.22 ± 25.35 vs. 60.23 ± 28.15 min, P = 0.23), and the use of total contrast volume (395.54 ± 180.25 vs. 406.15 ± 173.98 ml, P = 0.27) were similar in radial and femoral group, respectively. In hospital MACE [radial: 12 MI (3.8%) vs. femoral: 1 death (0.7%) and 5 MI (3.5%), P = 0.26] were similar in both groups. Access site vascular complications [radial: 11 (3.5%) vs. femoral: 17 (11.3%), P ≤ 0.001] were significantly less in radial group. Conclusions: The radial approach in CTO PCI is as fast and successful as the femoral approach with comparable in hospital MACE. However, there are far less access site complications with radial approach. © 2008 Wiley‐Liss, Inc.     

A novel technique of chronic total occlusion retrograde wire crossing by wiring into the antegrade microcatheter

We described a novel transradial retrograde wiring technique to treat chronic total occlusion (CTO) of the left anterior descending artery. When both retrograde wire and kissing wire technique failed to cross the CTO lesion, an antegrade microcatheter was placed in the CTO lesion. Then, a retrograde wire was manipulated into the antegrade microcatheter and subsequently exchanged and wire externalized. This technique appears to be feasible and safe alternative for retrograde wire crossing of the CTO lesion. It is a less traumatic modified version of controlled antegrade and retrograde subintimal tracking (CART) technique that can be attempted before embarking on CART or reverse CART strategy. © 2010 Wiley‐Liss, Inc.     

The confluent balloon technique for retrograde therapy of chronic total occlusion

Coronary chronic total occlusions (CTO) remain one of the most challenging lesions in percutaneous coronary intervention (PCI). Retrograde approach is an advanced PCI technique and can improve success rate in CTO intervention. Although success rate of this technique is high in experienced hands, there are still limitations in this approach, e.g., failure of wire to cross lesions. We report an easy and reliable new method of wire crossing in CTO lesions. In this technique, when both the antegrade and retrograde wires are in the subintimal space, balloons catheters are delivered in both directions to the site of the CTO. The balloons are then inflated simultaneously to create a common subintimal space (the confluent of subintimal space) which will allow crossing of wire to true lumen, either antegradely or retrogradely. This technique may improve the success rate of wire crossing and successful CTO intervention. © 2011 Wiley‐Liss, Inc.     

Antegrade rewiring of the retrograde Corsair catheter during revascularization of chronic total coronary occlusions: A simple alternative to guidewire exteriorization

Chronic total occlusions prevent a significant challenge to interventional cardiologists. Successful opening of chronically occluded vessels has been shown to be associated with decreased mortality and morbidity. Recently, the retrograde approach to chronic total occlusion intervention has been developed. In this case series, we present a novel technique to assist with this procedure involving antegrade wiring of a retrograde microcatheter. © 2011 Wiley Periodicals, Inc.     

A case of successful angioplasty by the “double retrograde” approach for chronic total occlusion in the left circumflex artery

Currently introduced retrograde approach may increase the success rate of percutaneous coronary interventions on chronic total occlusion (CTO) lesion. This article describes a case of CTO in the left circumflex artery (LCX), which did not allow the regular retrograde approach to deliver a guide wire. At first, a guide wire was attempted to advance from the apical collateral channel, which supplied the distal LCX. However, wiring was extremely difficult because the collateral channel was headed reversely against the direction that the wire was going. Different angle angiogram revealed the existence of another collateral artery, which supplied the distal RCA (posterior descending branch). A guide wire was successfully advanced from the distal RCA, through apical collateral channel, and reached the distal LCX. After the wire was retrieved from the guiding catheter engaged in the left main trunk, antegrade access for balloon and stent delivery was obtained. This method, a sort of “double retrograde” approach, would be worthy to consider when recanalization is failed by other approaches. © 2011 Wiley Periodicals, Inc.     

老年冠状动脉慢性完全性闭塞病变患者行逆向介入治疗的可行性

目的 探讨老年冠状动脉慢性完全闭塞（CTO）病变的患者行逆向介入治疗的可行性。方法 选择2004年1月至2015年5月沈阳军区总医院心内科收治的行逆向介入治疗的≥60岁老年CTO患者119例（老年组）及同期行逆向介入治疗的＜60岁CTO患者136例（非老年组）,对比分析两组患者逆向介入治疗手术成功率、治疗效果及并发症的发生率。结果 与非老年组比较,老年组更多合并高血压、糖尿病、脑血管疾病（均P＜0.05）;老年组欧洲心血管手术危险因素评分系统（EuroSCORE）评分明显高于非老年组（P＜0.001）。老年组合并双支和三支血管病变患者多于非老年组（均P＝0.000）;而老年组发生单支血管病变患者数低于非老年组（P＝0.000）。老年组SYNTAX评分高于非老年组,差异具有统计学意义（P＜0.001）。非老年组CTO时间为3～12个月的病例明显多于老年组,而老年组CTO时间为6～9年和＞9年的病例明显多于非老年组（均P＝0.000）。结论 本研究的结果表明逆向介入治疗对老年患者是安全有效的方法。     

The Anchor-Tornus technique: a novel approach to "uncrossable" chronic total occlusions.

Following successful guidewire passage, inability to cross a chronic total occlusion is the most frequent cause of procedural failure. While low-profile balloons, microcatheters, and specialty catheters such as the Tornus have been designed to facilitate lesion crossing, these devices require adequate guiding catheter support. We describe a novel application of the Tornus catheter combined with a balloon-anchored guide technique to successfully recanalize an otherwise difficult to cross chronic total occlusion.     

Double anchoring balloon technique for recanalization of coronary chronic total occlusion by retrograde approach

A retrograde approach through the collateral channels is considered to improve the success rate of percutaneous coronary intervention for coronary chronic total occlusion (CTO). Various kinds of strategies and techniques are required to improve the success rate of this novel approach. We describe a case in which a CTO was successfully recanalized by the retrograde approach, using a new anchoring balloon technique (double anchoring balloon technique) which enabled the successful balloon passage through the hard CTO lesion. © 2009 Wiley‐Liss, Inc.     

Retrograde recanalization of chronically occluded coronary arteries: illustration and description of the technique.

Chronic total occlusions remain one of the last frontiers in interventional cardiology, with far lower procedural success rates compared with other lesion subsets. The benefits of successful treatment include improvements in angina and survival. One method, which may improve technical success rates, is the use of a retrograde approach. We report three cases employing a retrograde approach and describe the technique in detail.