Outcomes of Retrograde Approach for Chronic Total Occlusions by Guidewire Location.

Background Connecting antegrade wire (AW) and retrograde wire (RW) is a goal of chronic total occlusion (CTO) treatment, but angiographic guide wire location is sometimes misleading. Aims To evaluate the association between intravascular ultrasound (IVUS) defined AW and RW position and procedural outcomes when treating CTO lesions using retrograde approach. Methods Overall, 191 CTO lesions treated with IVUS-guided retrograde approach at three centers in Japan, China, and United States were included. Results When the AW and RW angiographically overlapped, four wire positions were seen by 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 intra-plaque or sub-intimal passage . AW-subintima/RW-intraplaque was associated with the most complex CTO morphology and procedure and repositioning the wire was almost always necessary.