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Background: Retrograde chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is associated with lower success and higher complication rates when compared with the antegrade approach., Objectives: This study sought to assess contemporary techniques and outcomes of retrograde CTO PCI., Methods: We examined the baseline characteristics, procedural techniques and outcomes of 4,058 retrograde CTO PCIs performed at 44 centers between 2012 and 2023. Major adverse cardiac events (MACE) included any of the following in-hospital events: death, myocardial infarction, repeat target vessel revascularization, pericardiocentesis, cardiac surgery, and stroke., Results: The average J-CTO (Multicenter CTO Registry in Japan) score was 3.1 ± 1.1. Retrograde crossing was successful in 60.5% and lesion crossing in 81.6% of cases. The collaterals pathways successfully used were septals in 62.0%, saphenous vein grafts in 17.4%, and epicardials in 19.1%. The technical and procedural success rates were 78.7% and 76.6%, respectively. When retrograde crossing failed, technical success was achieved in 50.3% of cases using the antegrade approach. In-hospital MACE was 3.5%. The clinical coronary perforation rate was 5.8%. The incidence of in-hospital MACE with retrograde true lumen crossing, just marker antegrade crossing, conventional reverse controlled antegrade and retrograde tracking (CART), contemporary reverse CART, extended reverse CART, guide-extension reverse CART, and CART was 2.1%, 0.8%, 5.5%, 3.0%, 2.1%, 3.2%, and 4.1%, respectively; P = 0.01)., Conclusions: Retrograde CTO PCI is utilized in highly complex cases and yields moderate success rates with 5.8% perforation and 3.5% periprocedural MACE rates. Among retrograde crossing strategies, retrograde true lumen puncture was the safest. There is need for improvement of the efficacy and safety of retrograde CTO PCI., Competing Interests: Funding Support and Author Disclosures The Minneapolis Heart Institute Foundation; Science Center for Coronary Artery Disease (CCAD) helped support this research project. Study data were collected and managed using Research Electronic Data Capture. (REDCap) electronic data capture tools hosted at the Minneapolis Heart Institute Foundation (MHIF), Minneapolis, Minnesota. Dr Allana has been a consultant for Boston Scientific and Abiomed. D. Choi has received speaking honoraria from Shockwave. Dr Alaswad has been a consultant and speaker for Boston Scientific, Abbott Cardiovascular, Teleflex, and Cardiovascular Systems Inc. Dr Davies has received speaking honoraria from Abiomed, Asahi Intec, Boston Scientific, Medtronic, Siemens Healthineers, Shockwave, and Teleflex; and has served on advisory boards for Abiomed, Boston Scientific, Medtronic, and Rampart. Dr Karmpaliotis has received honoraria from Boston Scientific, Abbott Vascular, Abiomed; Equity: Saranas, Soundbite, and Traverse Vascular. Dr Jaffer has received research funding from Canon, Siemens, Shockwave, Teleflex, Mercator, Boston Scientific, HeartFlow, and Amarin; has been a consultant for Boston Scientific, Siemens, Magenta Medical, International Medical Device Solutions, Asahi Intecc, Biotronik, Philips, Intravascular Imaging, and DurVena; holds equity interest in Intravascular Imaging Inc, Massachusetts General Hospital, and DurVena; and has licensing arrangements with Terumo, Canon, and Spectrawave, for which he hast he right to receive royalties. Dr Khatri has received honoraria for proctoring and speaking from Abbott Vascular, Medtronic, Terumo, and Shockwave Medical. Dr Poommipanit has been a consultant for Medtronic, Asahi Intecc, and Abbott Vascular. Dr Azzalini has received consulting fees from Teleflex, Abiomed, GE Healthcare, Asahi Intecc, Philips, Abbott Vascular, Reflow Medical, and Cardiovascular Systems, Inc. Dr Nicholson has been a proctor and is on Speakers Bureau and advisory boards for Abbott Vascular, Boston Scientific, and Asahi Intecc; and holds intellectual property with Vascular Solutions. Dr Jaber has received consulting fees from Inari Medical and Medtronic. Dr Rinfret has been a consultant for Boston Scientific, Teleflex, Medtronic, Abbott, and Abiomed. Dr Brilakis has received consulting/speaker honoraria from Abbott Vascular, American Heart Association (as associate editor of Circulation), Amgen, Asahi Intecc, Biotronik, Boston Scientific, Cardiovascular Innovations Foundation (board of directors), ControlRad, CSI, Elsevier, GE Healthcare, IMDS, InfraRedx, Medicure, Medtronic, Opsens, Siemens, and Teleflex; has received research support from Boston Scientific and GE Healthcare; is the owner of Hippocrates LLC; and is a shareholder in MHI Ventures, Cleerly Health, and Stallion Medical. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Coronary calcification is common and increases the difficulty of chronic total occlusion (CTO) percutaneous coronary intervention (PCI)., Methods: We examined the impact of calcium on procedural outcomes of 13,079 CTO PCIs performed in 12,799 patients at 46 US and non-US centers between 2012 and 2023., Results: Moderate or severe calcification was present in 46.6% of CTO lesions. Patients whose lesions were calcified were older and more likely to have had prior coronary artery bypass graft surgery. Calcified lesions were more complex with higher J-CTO score (3.0 ± 1.1 vs. 1.9 ± 1.2; p < 0.001) and lower technical (83.0% vs. 89.9%; p < 0.001) and procedural (81.0% vs. 89.1%; p < 0.001) success rates compared with mildly calcified or non-calcified CTO lesions. The retrograde approach was more commonly used among cases with moderate/severe calcification (40.3% vs. 23.5%; p < 0.001). Balloon angioplasty (76.6%) was the most common lesion preparation technique for calcified lesions, followed by rotational atherectomy (7.3%), laser atherectomy (3.4%) and, intravascular lithotripsy (3.4%). The incidence of major adverse cardiovascular events (MACE) was higher in cases with moderate or severe calcification (3.0% vs. 1.2%; p < 0.001), as was the incidence of perforation (6.5% vs. 3.4%; p < 0.001). On multivariable analysis, the presence of moderate/severe calcification was independently associated with lower technical success (odds ratio, OR = 0.73, 95% CI: 0.63-0.84) and higher MACE (OR = 2.33, 95% CI: 1.66-3.27)., Conclusions: Moderate/severe calcification was present in nearly half of CTO lesions, and was associated with higher utilization of the retrograde approach, lower technical and procedural success rates, and higher incidence of in-hospital MACE., (Copyright © 2023 Elsevier B.V. All rights reserved.)