IVUS / Tsujita

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

Tsujita K, Maehara A, Mintz GS, Kubo T, Doi H, Lansky AJ, Stone GW, Moses JW, Leon MB, Ochiai M.

JACC Cardiovasc Interv. 2009 Sep;2 (9):846-54.

OBJECTIVES:

Evaluation of the results of the antegrade versus retrograde chronic total occlusion (CTO) technique with intravascular ultrasound (IVUS) imaging.

METHODS:

• 46 patients
• All de novo native coronary artery CTO lesions
• At the discretion of the operator, 23 lesions were treated via the antegrade approach (Ante) and 25 via the retrograde approach (Retro)
• Indications for the retrograde approach included: 1) occlusion length > 20 mm (visual evaluation); 2) visible, continuous collaterals; 3) healthy collateral-supplying vessel; 4) reattempt after previous CTO-PCI failure
• IVUS was performed in 48 lesions, immediately after crossing with an antegrade guidewire (in 5 lesions) or after pre-dilation with a 1.5- to 2.0-mm balloon

SUMMARY:

• 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 for long RCA CTOs. Intravascular ultrasound can be a useful tool for the detection of procedure-related vessel damage and subintimal wire tracking.

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