Coronary interventions - Mini focus on chronic total occlusions

Outcomes of retrograde approach for chronic total occlusions by guidewire location

EuroIntervention 2021;17:e647-e655. DOI: 10.4244/EIJ-D-20-01169

Yongzhen Fan
Yongzhen Fan1,2,3, MD; Akiko Maehara1,2, MD; Myong Hwa Yamamoto4, MD; Emad U. Hakemi2, MD, MSc; Khady N. Fall2, MD, MPH; Mitsuaki Matsumura1, BS; Ziad A. Ali1,2,5, MD, DPhil; Ajay J. Kirtane1,2, MD, SM; Jeffrey W. Moses1,2,5, MD; He Huang6, MD; Gary S. Mintz1, MD; Masahiko Ochiai4, MD, PhD; Dimitrios Karmpaliotis1,2, MD, PhD
1. Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA; 2. NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA; 3. Zhongnan Hospital of Wuhan University, Wuhan, China; 4. Showa University Hospital, Showa, Japan; 5. St. Francis Hospital, Roslyn, NY, USA; 6. Xiangtan Central Hospital, Xiangtan, China

Background: Connecting the antegrade wire (AW) and the retrograde wire (RW) is a goal of chronic total occlusion (CTO) treatment, but angiographic guidewire location is sometimes misleading.

Aims: The aim of this study was to evaluate the association between intravascular ultrasound (IVUS)-defined AW and RW position and procedural outcomes when treating CTO lesions using the retrograde approach.

Methods: Overall, 191 CTO lesions treated using an IVUS-guided retrograde approach at three centres in Japan, China, and the USA were included.

Results: When the AW and RW angiographically overlapped, four wire positions were seen on IVUS: (i) AW within the plaque (AW-intraplaque) and RW-intraplaque in 34%; (ii) AW-intraplaque and RW in the subintimal space (RW-subintima) in 28%; (iii) AW-subintima and RW-subintima in 22%; or (iv) AW-subintima and RW-intraplaque in 16%. The procedure succeeded without repositioning the wire in 89% of AW-intraplaque/RW-intraplaque, 61% of AW-intraplaque/RW-subintima and 57% of AW-subintima/RW-subintima, but only one (3%) AW-subintima/RW-intraplaque. Lesion and procedure complexity and failure/complications were greatest in AW-subintima/RW-intraplaque.

Conclusions: IVUS-identified vascular compartment concordance versus IVUS-identified vascular compartment mismatch leads to higher success rates irrespective of intraplaque or subintimal passage. AW-subintima/RW-intraplaque was associated with the most complex CTO morphology and procedure, and repositioning the wire was almost always necessary.

Visual summary. When the antegrade wire is in the subintimal space and the retrograde wire is in the intraplaque, re-wiring is almost always necessary.

Visual summary. When the antegrade wire is in the subintimal space and the retrograde wire is in the intraplaque, re-wiring is almost always necessary.

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