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Published on: November 24, 2014
Antegrade dissection and re-entry versus parallel wiring in chronic total occlusion percutaneous coronary
Bahadir Simsek1, Spyridon Kostantinis1, Judit Karacsonyi1
1Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA.
Insights
Antegrade dissection and re-entry (ADR) offers higher technical success than parallel wiring for chronic total occlusion percutaneous coronary intervention (PCI) after failed antegrade wiring. However, ADR is linked to increased major adverse cardiovascular events.
Area of Science:
- Interventional Cardiology
- Vascular Surgery
Background:
- The optimal strategy for complex chronic total occlusion (CTO) percutaneous coronary intervention (PCI) remains debated.
- Parallel wiring and antegrade dissection and re-entry (ADR) are techniques used when initial antegrade wiring fails.
Purpose of the Study:
- To compare the efficacy and safety of parallel wiring versus ADR in CTO PCI procedures.
- To analyze outcomes in patients undergoing CTO PCI after failed antegrade wiring.
Main Methods:
- A multicenter registry study included 1725 CTO PCI procedures.
- Patients were treated with either parallel wiring (692) or ADR (1033) following failed antegrade wiring.
- Clinical and angiographic data were collected and compared between the two groups.
Main Results:
- ADR patients were older with more comorbidities and higher CTO complexity scores (J-CTO, PROGRESS-CTO).
- Technical success was higher in the ADR group (78% vs. 75%), though procedural success was similar (75% vs. 73%).
- Major adverse cardiovascular events (MACE) were significantly higher in the ADR group (3.7% vs. 1.9%).
Conclusions:
- In CTO PCI cases where antegrade wiring fails, ADR demonstrates superior technical success compared to parallel wiring.
- ADR is associated with a higher incidence of MACE, necessitating careful consideration of risk-benefit.
- The choice between parallel wiring and ADR should be individualized based on patient and lesion characteristics.
Background:
The comparative efficacy and safety of parallel wiring versus antegrade dissection and re-entry (ADR) in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is controversial.
Methods:
We compared the clinical and angiographic characteristics and outcomes of parallel wiring versus ADR after failed antegrade wiring in a large, multicenter CTO PCI registry.
Results:
A total of 1725 CTO PCI procedures with failed antegrade wiring with a single wire were approached with parallel wiring (692) or ADR (1033) at the discretion of the operator. ADR patients were older (65 ± 10 vs. 62 ± 10, years, p < 0.001) and had higher prevalence of comorbidities, such as diabetes mellitus (43% vs. 32%, p < 0.001), prior coronary artery bypass graft surgery (31% vs. 19%, p < 0.001), and lower left ventricular ejection fraction (50 ± 14 vs. 53 ± 11%, p < 0.001). The ADR group had higher J-CTO (2.8 ± 1.1 vs. 2.1 ± 1.3, p < 0.001) and PROGRESS-CTO (1.6 ± 1.1 vs. 1.2 ± 1.0, p < 0.001) scores. Equipment use including guidewires, balloons, and microcatheters was higher, and the procedures lasted longer in the ADR group. Technical success (78% vs. 75%, p = 0.046) and major adverse cardiovascular events (composite of all-cause mortality, stroke, acute myocardial infarction, emergency surgery or re-PCI, and pericardiocentesis) (3.7% vs. 1.9%, p = 0.029) were higher in the ADR group, with similar procedural success (75% vs. 73%, p = 0.166).
Conclusion:
In lesions that could not be crossed with antegrade wiring, ADR was associated with higher technical but not procedural success, and also higher MACE compared with parallel wiring.
