Retrograde Approach for Percutaneous Recanalization of Coronary Chronic Total Occlusions; Contribution to Clinical Practice and Its Long-term Results.

AIMS: We evaluated the contribution of the retrograde approach to real-world practice over time and its long-term outcomes in chronic total occlusion (CTO)-percutaneous coronary intervention (PCI).

METHODS AND RESULTS: We evaluated 1,635 CTO procedures conducted at our high-volume center between 2003 and 2015. The retrograde approach has been actively adopted in practice since January 2007. The primary endpoint is target-vessel failure (TVF), a composite of cardiac death, target-vessel-related myocardial infarction, or target-vessel revascularization/re-occlusion. The technical success rate of CTO-PCI has increased from 79.5% to 87.1% since 2007, although the complexity of the CTOs has also significantly increased in that time (Japanese-CTO scores; from 1.8±1.2 to 2.0±1.1, P=0.03). The incidence of in-hospital major adverse cardiac and cerebrovascular events using the retrograde approach was 4.5%, which was comparable to the antegrade-only approach of 4.1% (P=0.58). The retrograde approach showed a higher 4-year TVF rate after successful stenting compared with the antegrade-only approach (17.1% vs. 9.4%, P=0.01) but this difference was mainly driven by a higher target-vessel revascularization/re-occlusion rate. Multivariable analysis revealed that renal dysfunction (hazard ratio [HR] 3.33, 95% confidence interval [CI] 1.42-7.83), acute coronary syndrome (HR 1.99, 95% CI 1.26-3.14), the Japanese-CTO score (per 1, HR 1.23, 95% CI 1.00-1.51), and a smallest stent diameter (per 1 mm, HR 0.39, 95% CI 0.21-0.74) (all P <0.05) were independently associated with TVF.

CONCLUSIONS: A retrograde approach contributes to the increased success of more complex CTO-PCI over time with an acceptable frequency of in-hospital complications and 4-year TVF rate.