Temporal Trends in Retrograde Crossing of Epicardial Collaterals in Chronic Total Occlusion Percutaneous Coronary Intervention

Abstract

Background. The use of retrograde crossings in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) provides higher technical success rates in CTO-PCI. However, the use of epicardial collaterals carries a higher complication risk. Methods and Results. In this study, we aimed to investigate the temporal trends in retrograde crossing of epicardial collaterals, introduction of new guidewires, in-hospital major adverse cardiovascular events (MACE), and technical success rates in a large, multinational registry. We demonstrate that technical success rates increased substantially from about 5%-10% to 76% in the past decade without a concomitant increase in MACE rate (~3% to 4%), likely associated with increased operator experience and introduction of new guidewires. In addition, we show that while high-volume centers have higher technical success, they also have higher perforation rates.

Key words: CTO-PCI, retrograde approach, epicardial collaterals

The retrograde approach has significantly increased the success rates of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). However, retrograde epicardial collateral crossing has been associated with a higher risk of complications.¹  Crossing the epicardial collaterals is more challenging and might carry a higher risk of complications than septal collateral crossing.² Epicardial collateral crossing is usually reserved for experienced operators and has had variable success rates.³ We examined temporal trends in the success of epicardial collateral crossing and equipment utilization in a large, multicenter, CTO-PCI registry (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention [PROGRESS-CTO; NCT02061436]). The study was approved by an institutional review board at each site.

Between 2012 and October 2021, retrograde crossing via epicardial collaterals was attempted in 491 CTO-PCIs. Mean age was 66 ± 10 years and 87% were men, with a high prevalence of comorbidities, such as hypertension (90%), diabetes mellitus (42%), dyslipidemia (92%), and prior coronary artery bypass graft surgery (45%). Overall, the retrograde epicardial crossing technical success rate was 76%. Procedural success (defined as technical success in the absence of in-hospital major adverse cardiovascular events [MACE]) was 72%; the incidence of in-hospital MACE (composite of death, acute myocardial infarction, stroke, re-PCI, emergency surgery, or pericardiocentesis) was 3.5%, perforation was 14%, and tamponade was 2.2%. The success of epicardial collateral crossing increased over time (Figure 1A), along with increased use of the SUOH 03 guidewire (Asahi Intecc) (Figure 1B). Higher-volume centers (>20 epicardial collateral crossing attempts) had higher technical success in retrograde epicardial collateral crossings (81% vs 66%; P<.001), similar MACE rates (3.7% vs 3.0%; P=.67), and higher coronary perforation rates (17% vs 7.7%; P<.01).

In conclusion, success rates of retrograde epicardial crossings have increased substantially from 2012 to 2021, without a concomitant increase in MACE, which is possibly due to the introduction of new guidewires and increasing operator experience.

Affiliations and Disclosures

From the ¹Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota; ²Department of Cardiology, Henry Ford Hospital, Detroit, Michigan; ³Gagnon Cardiovascular Institute Morristown Medical Center, New Jersey; ⁴Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; and 5Department of Cardiology, Acibadem Kocaeli Hospital, Kocaeli, Turkey.

The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Basir is a consultant for Abbott Vascular, Abiomed, Cardiovascular Systems, Inc (CSI), Chiesi, and Zoll. Dr Jaffer reports sponsored research for Canon, Siemens, Shockwave, Teleflex, Mercator, Boston Scientific; consultant for Boston Scientific, Siemens, Magenta Medical, IMDS, Asahi Intecc, Biotronik, Philips, and Intravascular Imaging, Inc; equity interest in Intravascular Imaging, Inc and DurVena; licensing arrangements with Massachusetts General Hospital for Terumo, Canon, Spectrawave, for which he has right to receive royalties. Dr Brilakis reports consulting/speaker honoraria from Abbott Vascular, American Heart Association (associate editor, Circulation), Amgen, Asahi Intecc, Biotronik, Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), ControlRad, CSI, Elsevier, GE Healthcare, IMDS, InfraRedx, Medicure, Medtronic, Opsens, Siemens, and Teleflex; research support from Boston Scientific, GE Healthcare; owner, Hippocrates LLC; shareholder, MHI Ventures, Cleerly Health, and Stallion Medical. Dr Alaswad reports consulting and speaker honoraria from Boston Scientific, Cardiovascular Systems, Abbott Vascular, and Teleflex. The remaining authors report no conflicts of interest regarding the content herein.

Manuscript accepted January 15, 2022.

Address for correspondence: Khaldoon Alaswad, MD, FACC, FSCAI, Director, Cardiac Catheterization Laboratory, Edith and Benson Ford Heart and Vascular Institute, Henry Ford Hospital & Health System, Clinical Assistant Professor of Medicine Wayne State University, 2799 W. Grand Blvd, Detroit, MI 48202. Email: kalaswad@gmail.com

References

1. Megaly M, Ali A, Saad M, et al. Outcomes with retrograde versus antegrade chronic total occlusion revascularization. Catheter Cardiovasc Interv. 2020;96(5):1037-1043. doi:10.1002/ccd.28616

2. Megaly M, Xenogiannis I, Abi Rafeh N, et al. Retrograde approach to chronic total occlusion percutaneous coronary intervention. Circ Cardiovasc Interv. 2020;13(5):e008900. doi:10.1161/circinterventions.119.008900

3. Mashayekhi K, Behnes M, Akin I, Kaiser T, Neuser H. Novel retrograde approach for percutaneous treatment of chronic total occlusions of the right coronary artery using ipsilateral collateral connections: a European centre experience. EuroIntervention. 2016;11(11):e1231-6. doi:10.4244/eijv11i11a244

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