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Antegrade dissection and re-entry vs retrograde strategy in chronic total occlusion percutaneous coronary
Maksymilian P Opolski1, Mateusz Spiewak2, Filip Machaj3
1Department of Interventional Cardiology and Angiology, National Institute of Cardiology, Warsaw, Poland.
Insights
The ADRENALINE trial compares antegrade dissection and re-entry (ADR) versus retrograde strategies for difficult chronic total occlusion percutaneous coronary intervention. It assesses procedural success, time, and patient outcomes in complex coronary interventions.
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Biology
Background:
- Antegrade wiring (AW) is standard for chronic total occlusion (CTO) percutaneous coronary intervention (PCI).
- Difficult CTO lesions often necessitate antegrade dissection and re-entry (ADR) or retrograde strategies.
- Limited comparative data exists between ADR and retrograde approaches for complex CTO PCI.
Purpose of the Study:
- To compare the efficacy and safety of ADR versus retrograde strategies in patients with difficult coronary CTO.
- To evaluate procedural outcomes, including guidewire crossing success and procedure time.
- To assess myocardial infarction and quality of life post-intervention.
Main Methods:
- The ADRENALINE study is a prospective, multicenter randomized trial.
- 121 patients with difficult CTO (J-CTO score ≥2) are planned for enrollment.
- Patients with failed/unattempted AW are randomized 1:1 to ADR or retrograde strategies.
Main Results:
- Co-primary endpoints include total procedure time and successful guidewire crossing.
- Secondary assessments involve cardiac troponin T, creatine kinase-MB, and cardiac magnetic resonance (CMR).
- Health status is evaluated using the Seattle Angina Questionnaire and Rose Dyspnea Scale.
Conclusions:
- ADRENALINE is the first randomized study comparing ADR and retrograde strategies for difficult CTO PCI.
- It will provide crucial data on procedural outcomes, CMR-detected myocardial infarction, and quality of life.
- Findings will inform optimal treatment strategies for complex coronary interventions.
Rationale:
While antegrade wiring (AW) is the most common initial strategy for chronic total occlusion (CTO) percutaneous coronary intervention (PCI), difficult CTO lesions frequently require either antegrade dissection and re-entry (ADR) or a retrograde strategy. Comparative data between ADR and the retrograde approach remain limited.
Design:
The Antegrade Dissection vs Retrograde re-ENtry And Load of Interventionalist Effort (ADRENALINE) is a prospective, multicenter randomized study with a superiority design. It is planned to enroll 121 patients with difficult coronary CTO (J-CTO score ≥2) referred for CTO-PCI in accordance with the hybrid algorithm. Subjects undergoing successful AW will be included in the observational arm. Patients with failed or unattempted AW will be randomized 1:1 to ADR or retrograde CTO crossing strategy (n = 74). All patients will undergo pre- and postprocedural laboratory testing (including cardiac troponin T and creatine kinase-MB), cardiac magnetic resonance (CMR) for late gadolinium enhancement, and health status assessment by the Seattle Angina Questionnaire and the Rose Dyspnea Scale. The co-primary endpoints are total procedure time and successful guidewire crossing. Additionally, the relationship between different recanalization strategies and stress among interventional cardiologists will be explored.
Conclusion:
ADRENALINE is the first randomized study of ADR vs retrograde strategy for difficult CTO PCI, assessing procedural outcomes, CMR-detected myocardial infarction, and 3-month quality of life.
Enrolment Status:
The first patient was enrolled on July 29, 2025. As of June 14, 2026, 45 patients (26 randomized, 19 observational) of the planned 121 patients have been enrolled.
Trials Registration:
Clinicaltrials.gov: Identifier, NCT06878729.
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