Impact of Crossing Strategy on Intermediate-Term Outcomes After Chronic Total Occlusion Percutaneous Coronary Interventions

BACKGROUND: There is ongoing controversy on the optimal crossing strategy selection for chronic total occlusion (CTO) percutaneous coronary intervention (PCI), especially on the relative merits of antegrade dissection/re-entry and the retrograde approach. METHODS: We retrospectively examined the clinical outcomes of 173 consecutive patients who underwent successful CTO PCI at our institution between January 2012 and March 2015. RESULTS: Mean age was 65 ± 8 years and 98% of the patients were men with high prevalence of diabetes (60%), prior coronary artery bypass graft surgery (31%) and prior PCI (54%). The successful CTO crossing strategy was antegrade wire escalation in 79 patients (45.5%), antegrade dissection/re-entry in 58 patients (33.5%), retrograde wire escalation in 11 patients (6.4%) and retrograde dissection and re-entry in 25 patients (14.5%). The retrograde approaches was more commonly used in lesions with interventional collaterals (p<0.0001), moderate/severe calcification (p=0.02), blunt stump (p=0.01) and a higher J-CTO score (p=0.0002). Specifically, the retrograde wire escalation was associated with a prior attempt to open the CTO (p=0.05), and the dissection and re-entry approaches for both antegrade and retrograde had a stronger correlation with bifurcation and the distal cap (p=0.004), higher CTO occlusion length (p<0.0001) and higher stent length (p<0.0001). Median follow-up was 11 months. The 12-month incidence of death, myocardial infarction, and acute coronary syndrome/target lesion revascularization/target vessel revascularization was 2.5%, 4.9%, and 24.4%, respectively and was similar across intimal and subintimal crossing strategies. CONCLUSION: Antegrade dissection/re-entry and retrograde approaches are frequently used during CTO PCI and were associated with similarly favorable intermediate-term outcomes as antegrade wire escalation.