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We thank Dr. Kandzari and colleagues for their interest in our study (1). We do not believe that the STAR technique applied to coronary vessels may be confused with the other techniques used in chronic total occlusion (CTO) recanalization. The STAR technique is a relatively quick and easy technique to gain the distal lumen of the vessel, but the re-entry into the true lumen of all main branches may be difficult, and even in these cases, the restoration of a normal flow is achieved in approximately half of cases (63% in our study).
As stated in their letter, the STAR technique “is uncommonly performed at leading CTO centers,” and this was the case at our center (STAR technique was used in only 5% of 1,035 CTO patients). It is obvious that this technique cannot be confused with other techniques of anterograde or retrograde CTO percutaneous coronary intervention (PCI) that include intended limited dissection such as the CART, the reverse CART, or re-entry using the BridgePoint device (BridgePoint Medical/Boston Scientific, Minneapolis, Minnesota).
The statement that in our study only one-half of the STAR technique patients underwent angiographic follow-up is misleading: angiography was performed in 28 of the 34 patients with successful STAR technique (82% follow-up rate).
Your statement “In summary, a predominantly antegrade wire-based strategy of CTO-PCI is associated with low success rates” cannot be shared because the large majority of CTO PCIs are performed using an anterograde approach, and the success rate in a high-volume center is largely >80%.
Finally, we like to add that the main finding of the study was not considered by Dr. Kandzari and colleagues: the everolimus-eluting stent was associated with a dramatic decrease in the risk of reocclusion compared with first-generation drug-eluting stents (odds ratio: 0.22). Dr. Kandzari and colleagues refer to an ongoing study that will provide “more detailed clinical outcomes specific to these methods” (NCT01435031): this study is a sponsored registry (Abbott Vascular) that will include 250 patients over a period of 33 months, the aim of which is the assessment of the performance of the sponsor devices (Xience stent, Progress wire, Mini-Trek catheter) in CTO. The study design does not include angiographic follow-up. We hope that with regard to the clinical performance of the everolimus-eluting stent, the result of the study will confirm the results of our studies (1,2) despite the smaller number of patients and the very long planned enrollment period.
- American College of Cardiology Foundation
- Valenti R.,
- Vergara R.,
- Migliorini A.,
- et al.