Procedural and longer-term outcomes of wire- versus device-based antegrade dissection and re-entry techniques for the percutaneous revascularization of coronary chronic total occlusions

Background: There are few data regarding the procedural and follow-up outcomes of different antegrade dissection/re-entry (ADR) techniques for chronic total occlusion (CTO) percutaneous coronary intervention (PCI).

Methods: We compiled a multicenter registry of consecutive patients undergoing ADR-based CTO PCI at four high-volume specialized institutions. Patients were divided according to the specific ADR technique used: subintimal tracking and re-entry (STAR), limited antegrade subintimal tracking (LAST), or device-based with the CrossBoss/Stingray system (Boston Scientific, Marlborough, MA). Major adverse cardiac events (MACE: cardiac death, target-vessel myocardial infarction and target-vessel revascularization) on follow-up were the main outcome of this study. Independent predictors of MACE were sought with Cox regression analysis.

Results: A total of 223 patients were included (STAR n=39, LAST n=68, CrossBoss/Stingray n=116). Baseline characteristics were similar across groups. Technical and procedural success was lower with STAR (59% and 59%), as compared with LAST (96% and 96%) and CrossBoss/Stingray (89% and 87%; p<0.001 for both). At 24-month follow-up, MACE rates were higher in STAR (15.4%) and LAST (17.5%), as compared with device-based ADR with CrossBoss/Stingray (4.3%, p=0.02), driven by TVR (7.7% vs. 15.5% vs. 3.1%, respectively; p=0.02). Multivariable Cox regression analysis identified wire-based ADR (STAR and LAST) and total stent length as independent predictors of MACE.

Conclusions: In this multicenter cohort of patients undergoing CTO PCI with ADR techniques, STAR had lower success rates, as compared with the CrossBoss/Stingray system and LAST. The CrossBoss/Stingray system was independently associated with lower risk of MACE on follow-up, as compared with wire-based ADR techniques.