Outcomes With Retrograde Versus Antegrade Chronic Total Occlusion Revascularization

Objectives: The aim of the study was to evaluate the outcomes of retrograde versus antegrade approach in chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Background: The retrograde approach has increased the success rate of CTO PCI but has been associated with a higher risk for complications. Methods: We conducted a meta-analysis of studies published between 2000 and August 2019 comparing the in-hospital and long-term outcomes with retrograde versus antegrade CTO PCI. Results: Twelve observational studies (10,240 patients) met our inclusion criteria (retrograde approach 2,789 patients, antegrade approach 7,451 patients). Lesions treated with the retrograde approach had higher J-CTO score (2.8 vs. 1.9, p < .001). Retrograde CTO PCI was associated with a lower success rate (80.9% vs. 87.4%, p < .001). Both approaches had similar in-hospital mortality, urgent revascularization, and cerebrovascular events. Retrograde CTO PCI was associated with higher risk of inhospital myocardial infarction (MI; odds ratio [OR] 2.37, 95% confidence intervals [CI] 1.7, 3.32, p < .001), urgent pericardiocentesis (OR 2.53, 95% CI 1.41–4.51, p = .002), and contrast-induced nephropathy (OR 2.12, 95% CI 1.47–3.08; p < .001). During a mean follow-up of 48 ± 31 months retrograde crossing had similar mortality (OR 1.79, 95% CI 0.84–3.81, p = .13), but a higher incidence of MI (OR 2.07, 95% CI 1.1–3.88, p = .02), target vessel revascularization (OR 1.92, 95% CI 1.49–2.46, p < .001), and target lesion revascularization (OR 2.08, 95% CI 1.33–3.28, p = .001). Conclusions: Compared with antegrade CTO PCI, retrograde CTO PCI is performed in more complex lesions and is associated with a higher risk for acute and long-term adverse events.