1. EuroPCR25th annual meeting of theEuropean Association ofPercutaneous CardiovascularInterventions (EAPCI)Paris20-23 May 2014

2. EuroPCR 2014Paris20-23 May 2014The key to retrograde success:Identifying obstacles in retrogradePCI of coronary CTOCommentary:Professor Andrew BoyleJohn Hunter Hospital, Newcastle 3. Date of preparation May 2014 BRI001132Disclaimer AstraZeneca abides by the Medicines Australia Code of Conduct (Edition 17) andAstraZeneca Global Policies, and as such will not engage in the promotion ofunregistered products or unapproved indications. These highlights have been suggested by a group of cardiologists who attendedEuroPCR 2014, compiled by an external medical writer and sponsored byAstraZeneca. AstraZeneca has obtained permission from EuroPCR, to utilise the selected content foreducational purposes. Statements of fact and opinions expressed are those of the speakers individually and,unless expressly stated to the contrary, are not the opinion or position of AstraZeneca.AstraZeneca does not endorse or approve, and assumes no responsibility for, thecontent, accuracy, or completeness of the information presented. Presentations areintended for educational purposes only and do not replace independent professionaljudgement. Please refer to the appropriate approved Product Information before prescribing anyagents mentioned in these highlights.AstraZeneca Pty Ltd, Alma Road, North Ryde 2113 ABN: 54 009 682 311 4. EuroPCR 2014Paris20-23 May 2014Dr IngibjorgGudmundsdottirUniversity Hospitalof Iceland,Reykjavik 5. EuroPCR 2014Paris20-23 May 2014Background Well-developed collaterals to a chronically occluded coronary arteryterritory indicate a favourable prognosis, maintain tissue viability andreduce the risk of LV impairment and infarct size, but are frequentlyinsufficient to render patients free of angina. Good collateral circulation can provide retrograde access for chronictotal occlusion PCI. Retrograde PCI is an advanced technique requiring considerable skilland experience. We aimed to identify the limiting steps in retrograde PCI and assess thelearning curve and success rate. 6. EuroPCR 2014Paris20-23 May 2014Methods We reviewed chronic total occlusion procedures and identified andreviewed all retrograde coronary interventions done at five UK PCIcentres over a two year period (2010-2012) 7. EuroPCR 2014Paris20-23 May 2014Procedures Total of 739 interventions for chronic total occlusion 241 of those had a retrograde attempt at the intervention, of which 141(59%) were successful via a retrograde channel. Another 36 cases (25%) were successful at a subsequent attempt. Right coronary artery was most commonly treated (69% of cases). Over the two year period, the percentage of chronic total occlusionstreated via a retrograde approach increased from 19 to 35%. 8. EuroPCR 2014Paris20-23 May 2014ObstaclesCause of failure was classified as: Failure to cannulate or navigate collateral Failure to cross collateral with equipment Failure to cross CTO with wire and join lumens Failure to cross CTO with equipment or failure to externalise the wire Exceeding maximum contrast load or complications. 9. EuroPCR 2014Paris20-23 May 2014ObstaclesMost common reasons for failure changed with time from primarily a failure to identify and wire septals/collateralsto failure to enter the true lumen from the retrograde subintimal space orto externalise the wire. 10. EuroPCR 2014Paris20-23 May 2014Learning curveRetrograde success became more common over the period reviewed,increasing from 54% to 62% per procedure overall, and with each centredemonstrating a learning curve. 11. EuroPCR 2014Paris20-23 May 2014Complications Procedure abandoned because of perforation in 2% of cases No life threatening complications. 12. EuroPCR 2014Paris20-23 May 2014Conclusions At these five UK centres, there was a sharp increase in retrogradecoronary interventions over two years with an improved success rate. Initial retrograde success rate was 59% but a further 25% of caseswere subsequently successful, highlighting that more than one attemptand combination of antegrade and retrograde skills is often required. Advances in equipment such as microcatheters and exchange wiresoccurred during this period, but increased experience and training ofoperators is likely to have contributed most to the successful retrogradetreatment of CTOs. 13. EuroPCR 2014Paris20-23 May 2014Commentary: Professor Andrew Boyle Treatment of chronic total occlusions of coronary arteries representsone of the last frontiers of interventional cardiology. This impressive study of real-world UK experience showed that PCI canbe an effective alternative to surgery for the treatment of CTOs. The study showed that there is a real learning curve for the procedure,and the results are likely to be operator-dependent. Appropriate training and experience, and very careful attention to detail,are essential in these types of complex interventions.