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Objectives: We sought to evaluate the impact of crossing strategy on the incidence of periprocedural myocardial infarction (PMI) during chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Background: The optimal technique for crossing coronary CTOs remains controversial. Methods: We retrospectively examined the incidence of PMI among 184 consecutive patients who underwent CTO PCI at our institution between 2012 and 2015. Creatine kinase-myocardial band fraction (CK-MB) and troponin were measured before and after PCI in all patients. PMI was defined as CK-MB increase !33 upper limit of normal (ULN). Results: Mean age was 65 6 8 years, 98% of patients were men, 57% had diabetes mellitus, 36% were current smokers, 38% had prior heart failure, 31% had prior coronary artery bypass graft surgery (CABG), and 55% had prior PCI. The retrograde approach was used in 38% of cases. As compared with antegrade wire escalation and antegrade dissection/re-entry, use of the retrograde approach was associated with higher J-CTO (Multicenter CTO Registry of Japan) scores (P < 0.0001), higher frequency of moderate or severe calcification (P 5 0.0061), longer CTO length (P < 0.0001), more frequent proximal cap ambiguity (P < 0.0001), and lower technical (P 5 0.0007) and procedural (P 5 0.0014) success. The frequency of PMI for the antegrade-only and retrograde cases was 10% and 33%, respectively (P 5 0.0001). On multivariate analysis, use of the retrograde approach and moderate/severe calcification were independently associated with higher incidence of PMI. Conclusions: As compared with antegrade-only crossing techniques, the retrograde approach is used in patients with more complex anatomy but may carry higher risk for PMI. V C 2016 Wiley Periodicals, Inc.

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Percutaneous coronary intervention (PCI) of coronary chronic total occlusions (CTO) can be challenging. Although several crossing techniques are available, in some cases their application fails to cross the occlusion. Carlino et al. have pioneered the technique of hydraulic microdissection by contrast injection through a microcatheter inserted into the lesion. We report two CTO PCI cases in which the use of the Carlino technique enabled success after other crossing strategies failed to cross the occlusion. © 2016 Wiley Periodicals, Inc.