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Trends and Outcomes of Antegrade Dissection and Re-Entry in Chronic Total Occlusion Percutaneous
Athanasios Rempakos1, Michaella Alexandrou1, Bahadir Simsek1
1Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA.
Insights
Antegrade dissection and re-entry (ADR) use in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has decreased. ADR is associated with more complex lesions, lower success rates, and higher adverse events compared to non-ADR cases.
Area of Science:
- Cardiovascular Interventions
- Interventional Cardiology
- Vascular Access Techniques
Background:
- Antegrade dissection and re-entry (ADR) techniques for chronic total occlusion (CTO) percutaneous coronary intervention (PCI) are not well-studied.
- Limited data exists on the contemporary frequency and outcomes of ADR in CTO PCI.
Purpose of the Study:
- To determine the frequency and outcomes of ADR utilization within a large multicenter CTO PCI registry.
- To analyze trends in ADR use and associated procedural success and complications.
Main Methods:
- Retrospective analysis of 12,841 CTO PCI procedures from 2012-2023 across 46 centers.
- Examination of patient characteristics, angiographic complexity, and procedural outcomes for ADR versus non-ADR cases.
- Analysis of trends in specific ADR device utilization (CrossBoss, Stingray, STAR).
Main Results:
- ADR was used in 18.6% of procedures, with a significant decline in use from 37.9% in 2012 to 14.5% in 2022.
- ADR cases presented with higher lesion complexity (J-CTO score) and comorbidities.
- ADR use was linked to lower technical success (77.0% vs 89.3%) and higher in-hospital MACE (3.7% vs 1.6%) compared to non-ADR cases.
- Stingray device use decreased, while Subintimal Tracking and Re-entry (STAR) became the predominant re-entry technique.
Conclusions:
- The utilization of ADR in CTO PCI has decreased significantly over the study period.
- ADR is employed in more complex CTO lesions and is associated with inferior technical success and increased adverse events.
- Shifting trends in re-entry techniques favor STAR over Stingray for ADR procedures.
Background:
The contemporary frequency and outcomes of antegrade dissection and re-entry (ADR) for chronic total occlusion (CTO) percutaneous coronary intervention (PCI) have received limited study.
Objectives:
The aim of this study was to determine the frequency and outcomes of ADR use in a large multicenter CTO PCI registry.
Methods:
The characteristics and outcomes of ADR were examined among 12,568 patients who underwent 12,841 CTO PCIs at 46 U.S. and non-U.S. centers between 2012 and 2023.
Results:
ADR was used in 2,385 of the procedures (18.6%). ADR use declined from 37.9% in 2012 to 14.5% in 2022 (P < 0.001). Patients in whom ADR was used had a high prevalence of comorbidities. Compared with cases that did not use ADR, ADR cases had more complex angiographic characteristics, higher mean J-CTO (Multicenter CTO Registry in Japan) score (2.94 ± 1.11 vs 2.23 ± 1.26; P < 0.001), lower technical success (77.0% vs 89.3%; P < 0.001), and higher in-hospital major adverse cardiac events (3.7% vs 1.6%; P < 0.001). The use of the CrossBoss declined from 71% in 2012 to 1.4% in 2022 and was associated with higher technical success (87%) compared with wire-based techniques (73%). The Stingray device displayed higher technical success (86%) compared with subintimal tracking and re-entry (STAR) (74%) and limited antegrade subintimal tracking (78%); however, its use has been decreasing, with STAR becoming the most used re-entry technique in 2022 (44% STAR vs 38% Stingray).
Conclusions:
The use of ADR has been decreasing. ADR was used in more complex lesions and was associated with lower technical success and higher major adverse cardiac events compared with non-ADR cases. There has been a decrease in Stingray use and an increase in the use of STAR for re-entry.
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