TCT-334 Technical Analysis and Procedural Outcomes of Retrograde Approach to Chronic Total Occlusion Percutaneous Coronary Interventions: Insights From an International Multicenter Registry

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Background: Retrograde chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is associated with lower success and higher complication rates compared with antegrade approach. Methods: We examined baseline characteristics, procedural techniques and outcomes of 4,058 retrograde CTO PCIs performed at 44 centers between 2012 and 2023. Major adverse cardiac events (MACE) included any of the following in-hospital events: death, myocardial infarction, repeat target-vessel revascularization, pericardiocentesis, cardiac surgery, and stroke. Results: The average J-CTO score was 3.1 ± 1.1. Retrograde crossing was successful in 60.5% and lesion crossing in 81.6% of cases. The collaterals pathways successfully used were septals in 62.0%, saphenous vein grafts in 17.4%, and epicardials in 19.1%. Epicardial collateral perforation was associated with significantly higher incidence of in-hospital MACE (14.0% vs 3.3%; P < 0.001) while there was no significant difference in in-hospital MACE with septal collateral perforation (2.3% vs 3.5%; P = 0.66). The technical and procedural success rates were 78.7% and 76.6%, respectively. When retrograde crossing failed, technical success was achieved in 50.3% of cases using an antegrade approach. In-hospital MACE was 3.5%. The coronary perforation rate was 9.5%. The incidence of in-hospital MACE with retrograde true lumen crossing, just marker antegrade crossing, conventional reverse controlled antegrade and retrograde tracking (CART), contemporary reverse CART, extended reverse CART, guide-extension reverse CART, and CART was 2.1%, 0.8%, 5.5%, 3.0%, 2.1%, 3.2%, and 4.1%, respectively; P = 0.01). Conclusion: Retrograde CTO PCI is utilized in cases with high lesion complexity and yields moderate success rates with 9.5% perforation and 3.5% peri-procedural MACE rates. Use of septal collateral was associated with the lowest risk of coronary perforation. Epicardial collateral perforation resulted in high rate of in hospital MACE. Among retrograde crossing strategies, retrograde true lumen puncture was the safest. Guide extension reverse CART has a good balance of feasibility and safety. There is need for improvement in efficacy and safety of retrograde CTO PCI. Categories: CORONARY: Complex and Higher Risk Procedures for Indicated Patients (CHIP)

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