Korean Circ J.  2009 Jun;39(6):228-235. 10.4070/kcj.2009.39.6.228.

Initial Experience of Retrograde Wire Approach in Coronary Chronic Total Occlusion Intervention

• Chung SH
• Kim MH
• Yu LH
• Park JS
• Kim KH
• Kum DS
• Park TH
• Cha KS
• Kim YD

• KMID: 1490698
• DOI: http://doi.org/10.4070/kcj.2009.39.6.228

Abstract

BACKGROUND AND OBJECTIVES: Retrograde wire approach has been emerged as a useful tool to enhance success rate in coronary chronic total occlusion (CTO) intervention. Therefore, we tried to report the initial experience of retrograde approach and its clinical implication on CTO intervention.
SUBJECTS AND METHODS
From February 2007 to July 2008, retrograde approaches were performed in 28 patients with 31 CTO lesions out of 61patients. A hydrophilic coated guidewire was inserted by using microcatheter or over-the-wire (OTW) balloon through the collateral channel (septal or epicardial artery) via several strategies.
RESULTS
Mean age of patients was 63.4+/-11.6 years. Male and female were 20 and 8 patients, respectively. The target artery with CTO lesions included the right coronary artery (45.2%), the left anterior descending artery (51.6%), and the left circumflex artery (3.2%). The mean length of CTO lesion was 18.4+/-16.4 mm. Overall technical success rate was 64.5%. The success rate of primary attempt was 78.9%, while the success rate of immediate and secondary attempt was 41.7%. Collateral channel dissections were observed in 3 patients and no patients among these patients developed cardiac tamponade. One patient had a silent non-Q wave myocardial infarction (MI) after the procedure. One failed patient died suddenly 3 days after the procedure. After percutaneous coronary intervention (PCI) procedure, no case was performed target vessel revascularization (TVR), urgent coronary artery bypass graft (CABG), and urgent PCI.
CONCLUSION
Retrograde approach is an evolving technique to improve the success rate of CTO intervention. After the learning curve period, this technique could be the useful tool to enhance success rate in CTO intervention.

Keyword

Coronary occlusion; Collateral circulation

MeSH Terms

Arteries
Cardiac Tamponade
Collateral Circulation
Coronary Artery Bypass
Coronary Occlusion
Coronary Vessels
Female
Glycosaminoglycans
Humans
Learning Curve
Male
Myocardial Infarction
Percutaneous Coronary Intervention
Transplants
Glycosaminoglycans

Figure

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  Fig. 1 Illustration of cutting method. A, B and C: selection of sheath which size 1 Fr less than guiding catheter size and cutting off the sheath about 4 cm length. D, E and F: guiding catheter was cut off 10-15 cm of catheter shaft proximal to sheath and two ends were connected with 4 cm sheath.

• 

  Fig. 2 An example of landmark technique. A: proximal left anterior descending coronary artery (LAD) occlusion. B: route of collateral artery. C: a hydrophilic GW reached to distal cap of LAD CTO lesion and antegrade GW successfully crossed through CTO lesion. D: final result after drug-eluting stent implantation. GW: guide wire, CTO: chronic total occlusion.

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  Fig. 3 An example of proximal kissing wire technique. A: proximal left anterior descending coronary artery (LAD) occlusion. B: retrograde GW reached to distal cap of the CTO lesion. C: retrograde GW advanced to proximal cap of the CTO lesion. D: successful antegrade GW crossing after retrograde GW advanced. E: final result after drug-eluting stent insertion. GW: guide wire, CTO: chronic total occlusion.

• 

  Fig. 4 An example of loop method. A: proximal left anterior descending coronary artery (LAD) occlusion. B: a hydrophilic GW crossed through collateral channel into distal part of LAD. C: retrograde GW successfully crossed through the CTO lesion into antegrade guiding catheter (GC). D: microcatheter was advanced into antegrade GC by balloon anchoring technique. E: retrograde GW was exchanged to 300 cm GW, and then the 300 cm GW was pushed into antegrade GC and caught at the opposite sheath. F: a balloon insertion over the 300 cm GW and ballooning at the lesion site. G and H: antegrade GW was successfully crossed through the lesion into the distal part. I: final result after ballooning and stent implantation. CTO: chronic total occlusion.

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  Fig. 5 An example of CART technique. A and B: unsuccessful parallel wire technique was done antegradely. C and D: successful retrograde GW was crossed through the septal collateral channel and put into subintimal space of the CTO lesion. E: ballooning in the subintimal space of the CTO lesion retrogradely. F: antegrade GW was advanced successfully into distal true lumen crossing the target space of CTO leion. G: insertion of drug-eluting stent. H: image after stent insertion. CART: controlled antegade and retrograde subintimal tracking, GW: guide wire, CTO: chronic total occlusion.

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