Antegrade versus retrograde techniques for Chronic Total Occlusions (CTO): a review and comparison of techniques and outcomes

ABSTRACT

Introduction: As the field of chronic total occlusion percutaneous coronary intervention has evolved, technical approaches have evolved and been refined.

Areas covered: In this review, we discuss the major techniques utilized in modern CTO PCI including antegrade wiring, antegrade dissection reentry, retrograde wiring, and retrograde dissection reentry. Retrograde techniques have been extensively studied in comparison to antegrade techniques. Retrograde techniques have contributed to increases in CTO PCI success rates and are generally used in higher complexity lesions. Observational data ssuggestincreased sshort-termcomplications in procedures requiring the use of retrograde techniques; however, llong-termCTO PCI durability and patient outcomes have been shown to be similar among procedures using antegrade only versus retrograde techniques.

Expert opinion: Retrograde techniques play a vital role in the technical success of CTO PCI, particularly among more complex lesions and in patients with high burdens of comorbidities. Increases in procedural safety with equipment iteration and in the use of adjunctive imaging will play an important role in the selection of appropriate retrograde conduits and the overall success rates of CTO PCI.

KEYWORDS:

• Chronic total occlusion
• antegrade techniques
• retrograde techniques
• complications
• perforation

Article highlights

• Antegrade wiring is the most commonly used technique to cross chronic total occlusions and is comprised of proximal cap puncture, CTO body crossing, and distal cap puncture.

• The antegrade dissection reentry technique involves accessing the subintimal space, extra plaque traversing of the CTO body, and distal reentry which can be achieved with multiple dedicated techniques.

• Retrograde crossing of septal, epicardial, and SVG collaterals is the success limiting step of retrograde CTO PCI techniques.

• Retrograde CTO PCI techniques are used in higher complexity lesions and patients.

• Retrograde true to true and retrograde dissection/reentry techniques have higher rates of complications than antegrade only techniques.

• Improvements in the safety of equipment and techniques continue to make antegrade and retrograde CTO PCI more successful and safer.

Declaration of interest

K Alaswad has received consultant and speaking fees from Abbott vascular, Boston Scientific, Cardiovascular Systems Incorporated and Teleflex. S Neupane is a consultant for Cardiovascular Systems and serves as a speaker for Abiomed. MB Basir has received consulting fees from Abbott Vascular, Abiomed, Cardiovascular Systems, Chiesi, Procyrion and Zoll. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose

Additional information

Funding

This paper was not funded.