Author + information
- David E. Kandzari, MD⁎ (, )
- J. Aaron Grantham, MD,
- William Lombardi, MD and
- Craig Thompson, MD
- ↵⁎Piedmont Heart Institute, Suite 300, 275 Collier Road, Atlanta, Georgia 30309
Recently, Valenti et al. (1) reported clinical and angiographic outcomes after chronic total occlusion (CTO) revascularization with drug-eluting stents (DESs). In this retrospective analysis, the investigators demonstrated 77% procedural success with wire-based CTO crossing strategies and concluded that although treatment with DESs in this complex lesion subset is associated with favorable angiographic patency, CTO percutaneous coronary intervention (PCI) involving subintimal tracking and luminal re-entry (STAR) techniques was independently predictive of recurrent occlusion. Specifically, among a small cohort of 54 patients, recanalization was accomplished in 50 of them, yet final Thrombolysis In Myocardial Infarction flow grade 3 was achieved in only 34 patients (63%). At 1 year, a 57% reocclusion rate (31/54 attempts) was demonstrated, but only half of the STAR group underwent angiographic follow-up. Reduced 3-year event-free survival was also described in comparison with patients treated with non-STAR techniques.
We believe that these findings represent misinterpretation in what is considered subintimal dissection and re-entry CTO PCI and may therefore be misleading regarding the advantages of the current CTO PCI technique. First, the STAR technique is traditionally used as a bail-out maneuver for distal lumen entry through creation of extensive subintimal dissection planes, often with the unintended consequence of side branch loss. As exemplified in this and previous (2) studies, it is an unfavorable method associated with low procedural and clinical success. Moreover, the long-term success of this method is dependent on infrequent achievement of final TIMI flow and preservation of distal vessel runoff that are instead the objectives of more targeted re-entry techniques. For these reasons, STAR is uncommonly performed at leading CTO centers and should not be confused with more limited and contemporary subintimal dissection and re-entry methods. Indeed, it is likely that the majority of all successful CTO recanalization procedures involve guidewire advancement through the subintimal vessel architecture, further confounding what defines subintimal and nonsubintimal CTO PCI (3).
In summary, a predominantly antegrade wire-based strategy of CTO-PCI is associated with low success rates. The STAR technique and related outcomes described by Valenti et al. do not represent more common (and contemporary) CTO PCI methods that involve targeted guidewire re-entry. The expected adverse outcome described in the present study should therefore not discourage the application of more contemporary methods of luminal re-entry that facilitate procedural success (4). More detailed clinical outcomes specific to these methods will be reported from the ongoing clinical study (NCT01435031).
Please note: Dr. Kandzari has received research/grant support from Abbott Vascular, Medtronic, and Boston Scientific and consulting honoraria from Medtronic and Boston Scientific. Dr. Grantham has received research/grant support from Abbott Vascular, Medtronic, Asahi, and BridgePoint Medical/Boston Scientific and consulting honoraria from Abbott Vascular, Asahi, BridgePoint Medical/Boston Scientific, and Vascular Solutions. Dr. Lombardi has equity in BridgePoint Medical/Boston Scientific. Dr. Thompson has equity in BridgePoint Medical/Boston Scientific and receives consulting honoraria from Abbott Vascular and Terumo Medical.
- American College of Cardiology Foundation