1. Retrograde approach for the Recanalizaiton of Coronary CTO: Preliminary Experience of Single Centre Lei Ge, Juying Qian, Xuebo Liu, Qin Qing, Junbo Ge Department of Cardiology, Zhongshan Hospital,Fudan University Shanghai Institute of Cardiovascular Diseases

2. 1.The success rate of antegrade approach for the complex CTO recanalization has not dramatically increased. Retrograde techniques may hold great promise. 2.However, this new therapeutic concepts have not been systemically evaluated in our practice environment. Background Retrograde approach for the Recanalizaiton of CTO: Preliminary Experience of Single Centre

3. Aim of this Study The purpose of this study is to describe our experiences of retrograde PCI for CTO, focusing on its safety and feasibility Retrograde approach for the Recanalizaiton of CTO: Preliminary Experience of Single Centre

4. 1.Patients with coronary CTO who were attempted with retrograde techniques, either as the primary strategy (intended initial strategy) or reattempted way were identified from July 2005 to November 2009. 2.No clinical exclusion criteria were applied. Retrograde approach for the Recanalizaiton of CTO: Preliminary Experience of Single Centre Study population

5. 1.CC0: no continuous connection between donor and recipient artery; 2.CC1: continuous, threadlike connection; 3.CC2: continuous, small side branch-like size of the collateral throughout its course. Clinical Definition and Methods (1) Angiographic assessment collateral connection (CC) was based on the classification of Werner’s: Retrograde approach for the Recanalizaiton of CTO: Preliminary Experience of Single Centre

6. cardiac death myocardial infarction (MI) target vessel revascularization (TVR), either percutaneous or surgical Clinical Definition and Methods (2) Retrograde approach for the Recanalizaiton of CTO: Preliminary Experience of Single Centre MACE was defined as ：

7. Indication of Retrograde approaches Retrograde approach for the Recanalizaiton of CTO: Preliminary Experience of Single Centre

8. Different of Retrograde Strategies Retrograde approach for the Recanalizaiton of CTO: Preliminary Experience of Single Centre 1.Retrograde approach as the primary strategy 2.Retrograde approach immediately after failed antegrade attempt 3.Retrograde approach as elective procedure in patients with previously failed antegrade attempt

9. Different of Retrograde Wire Techniques Retrograde GW cross CTO Antegrade GW cross CTO Dedicated Devices Needed Kissing wire techniqueYes No Retrograde wire crossing techniqueYesNo Short GC and long-shaft balloons CART or Reverse CART techniqueNo Short GC and long-shaft balloons Retrograde wire trapping techniqueYesNoSnare Reverse Retrograde wire trapping technique YesNoSnare Back-End ballooning + MC reversalYesNo300cm GW Retrograde approach for the Recanalizaiton of CTO: Preliminary Experience of Single Centre

10. From July 2005 to November 2009, 42 patients underwent PCI for CTO using the retrograde approach were identified in our center. CharacteristicN (%) Age (year) 62.8±11.6 Male41(97.6) Prior MI23(54.8) Prior CABG2(4.8) Stable angina27(64.3) Unstable angina15(35.7) LVEF (%) 57.0±9.9 Mean occlusion duration (months) 36.0±33.6 Previous failed antegrade attempt10 (23.8) Baseline clinical characteristics (n=42) Retrograde approach for the Recanalizaiton of CTO: Preliminary Experience of Single Centre

11. Characteristic N (%) Stump morphology Tapered16(38.1) Blunt26(61.9) Side branch/bridging at level of occlusions33(78.6) Proximal vessel segment tortuosity7(16.7) Calcification20(47.6) Ostial location of occlusions13(31) Occlusion length (mm) 29.4±12.0 Collateral connection (CC) grade CC 01 (2.4) CC 117 (40.5) CC 224 (57.1) Angiographic characteristics Retrograde approach for the Recanalizaiton of CTO: Preliminary Experience of Single Centre

12. Characteristic N (%) Collateral accessed Septal39(92.9) Epicardial2(4.8) SVG1(2.4) Collateral crossing wire (n=34) Runthrough15 (44.1) Fielder9 (26.5) Fielder FC9 (26.5) Fielder XT1 (2.9) CTO retrograde crossing wire (n=30) Runthrough1 (3.3) Whisper1 (3.3) Fielder2 (6.6) Fielder FC4 (13.3) Fielder XT1 (3.3) Crosswire NT18 (60.0) Miracle2 (6.6) Conquest Pro1 (3.3) Procedural characteristics (1) Retrograde approach for the Recanalizaiton of CTO: Preliminary Experience of Single Centre

13. Procedural characteristics (2) Characteristic N (%) Channel Dilator utilized 11 (26.2) Tornus utilized1 (2.4) Mean contrast volume consumption (ml) 647.6±219.2 Retrograde as primary strategy 590.5±193.4 Retrograde immediately after failed antegrade attempt 809.1±180.0 Retrograde after previous failed antegrade attempt590.0±237.8 Retrograde approach for the Recanalizaiton of CTO: Preliminary Experience of Single Centre

14. Retrograde strategy and successful rates Retrograde approach for the Recanalizaiton of CTO: Preliminary Experience of Single Centre N=21 N=11N=10

15. Flow Diagram of the Procedure Overall success rate: 88.1% Retrograde approach for the Recanalizaiton of CTO: Preliminary Experience of Single Centre

16. CharacteristicN (%) Procedural complication Collateral dissection1(2.4) Collateral perforation1(2.4) Tamponade1(2.4) Non-target vessel thrombosis1(2.4) Dissection of donor vessel0 Wire or devices entrapment0 Stent thrombosis0 In-hosptial MACE3 (7.1) Myocardial infarction3(7.1) Death0 TVR0 Procedural complications and in-hospital outcomes Retrograde approach for the Recanalizaiton of CTO: Preliminary Experience of Single Centre

17. Summary Retrograde approach for the Recanalizaiton of CTO: Preliminary Experience of Single Centre 1)Overall success rate of recanalization was 88.1%. 2)Retrograde guidewire successful crossed collateral in 34 (80.9%) cases, success rate in this group was 94.1%. 3)In patients with guidewire failure to cross the collaterals, the success rate of antegrade approach was 62.5%; 4)In-hospital MACE was 7.1%.

18. 1.Single center, small size observational study with short-term follow-up is the major limitation of this report. 2.With regard retrograde approach, a learning curve clearly exists and its success rate is case volume dependent. Accordingly, it may not be reasonable that the results of this study are universally reproduced to all operators. Limitations Retrograde approach for the Recanalizaiton of CTO: Preliminary Experience of Single Centre

19. 1.The retrograde approach can be an effective tool for increasing the success rate of recanalization in the very complex CTOs. 2.However, we are far from considering the retrograde approach as a mainstream procedure for all complex CTO at present. Clinical Implications Retrograde approach for the Recanalizaiton of CTO: Preliminary Experience of Single Centre

20. 谢 谢谢 谢谢 谢谢 谢 Thank You 2010-3