Retrograde approach for the percutaneous recanalisation of coronary chronic total occlusions: Contribution to clinical practice and long-term outcomes

Aims: We aimed to evaluate 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 centre between 2003 and 2015. The retrograde approach has been actively adopted in practice since January 2007. The primary endpoint was target vessel failure (TVF), a composite of cardiac death, target vessel-related myocardial infarction, or target vessel revascularisation/reocclusion. 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 (J-CTO scores: From 1.8±1.2 to 2.0±1.1, p=0.03). The incidence of in-hospital MACCE using the retrograde approach was 4.5%, which was comparable to the antegrade-only approach rate of 4.1% (p=0.58). The retrograde approach showed a higher four-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 revascularisation/reocclusion 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 J-CTO score (per 1, HR 1.23, 95% CI: 1.00-1.51), and the 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 four-year TVF rate.