Retrograde approach for revascularization of a coronary chronic total occlusion with review of literature

Abstract

Not every coronary occlusion results in an acute coronary syndrome(ACS). The occlusion can develop gradually, allowing collateral circulation formation. If this circulation does not suffice ischaemia in the underperfused myocardial region will causa angina during exercise or progressive symptoms of heart failure. Chronic total conclusion(CTO) of a coronary artery is defined as a complete occlusion(TIMI grade 0 flow) for 3 months or longer. Such occlusions differ from 'recent'(≥3 days) due to an ACS. In this situation, late revascularization has not proven to be superior to optimal medical treatment in the recent TOSCA-2 trial and OAT-trial. Generally, in an ACS there is no or little collateral circulation and after more than 3 days, the regional myocardial viability is lost, which makes a percutaneous coronary intervention (PCI) useless at that time. Recanalization of a CTO can be challenging. First an antegrade approach is used. Depending on the lesion attempted, success rates vary between 50 and 80%. A hard 'proximal fibrous cap' can make it impossible to penetrate and cross the lesion, even with specially designed guide wires. Since 1990, the retrograde approach was developed by Japanese interventionalists to overcome this problem. We present a case of a succesful retrograde recanalization of a CTO of a proximal right coronary artery(RCA) using the reverse CART technique.