Multicenter experience with the antegrade fenestration and reentry technique for chronic total occlusion recanalization

Abstract

Objectives: We aimed to evaluate the efficacy and safety of antegrade fenestration and reentry (AFR) for chronic total occlusion (CTO) recanalization in a multicenter registry. Background: Adoption of antegrade dissection/reentry (ADR) for CTO recanalization has been limited, and novel ADR techniques are needed. Methods: AFR involves the balloon-induced creation of multiple fenestrations between the false and true lumen. A targeted true lumen reentry is subsequently achieved with a low tip-load polymer-jacketed guidewire. Following the initial description and dissemination of AFR, patients undergoing AFR-based CTO recanalization at nine centers were included in the present registry. Study endpoints were AFR success, procedural success, and target-lesion failure (TLF) on follow-up. Results: We included 41 patients. Mean J-CTO score was 2.5 ± 1.4. In 80.5% of cases, AFR was performed after failed antegrade wire escalation. Another ADR technique was used before AFR in one-third of cases. AFR achieved distal true lumen reentry in n = 27/41 (65.9%) cases. In n = 14/41 (34.1%) cases with AFR failure, use of alternative techniques led to successful CTO recanalization in eight additional patients. The overall technical and procedural success rates were 85.4% and 82.9%, respectively. No AFR-related complications were observed. One-year TLF rate was 8.3% overall, with no differences between successful and failed AFR. Conclusions: We report on AFR feasibility in a multicenter registry of patients undergoing CTO recanalization. We observed a moderate success rate, coupled with the absence of complications. Moreover, even a failed AFR attempt did not preclude the use of alternative techniques to achieve recanalization. Further studies should confirm and extend our findings.

Dual guidewire balloon antegrade fenestration and re‐entry technique for coronary chronic total occlusions percutaneous coronary interventions

“…19 In another multicenter United States Registry, among successful ADR cases, the Stingray catheter was the most successfully used re-entry method. 17 However, a stepwise learning curve, a need for dedicated proctored training, and a no-negligible rate of failure mostly due to inability to "poke" through calcified tissue, 11 has reduced the acceptance of the Stingray catheter-based ADR from 55% 16 to 32% 20 in the community which embraces the hybrid algorithm, and is negligible in others. 1,21 Very recently Carlino et al, 10 global CTO crossing algorithm created on the basis of four previous consensus documents from North America, 2 China, 22 Japan, 21 Europe, 3 and including also 122 operators from 50 countries that facilitate decision making and CTO PCI teaching across geographies, improving the safety, reproducibility, and efficiency of the procedure.…”

“…In another multicenter United States Registry, among successful ADR cases, the Stingray catheter was the most successfully used re‐entry method 17 . However, a stepwise learning curve, a need for dedicated proctored training, and a no‐negligible rate of failure mostly due to inability to “poke” through calcified tissue, 11 has reduced the acceptance of the Stingray catheter‐based ADR from 55% 16 to 32% 20 in the community which embraces the hybrid algorithm, and is negligible in others 1,21 …”

“…These transient fenestrations are then traversed by a polymer‐jacketed wire to achieve true lumen re‐entry. A subsequent multicentre experience confirmed the feasibility and safety of such a technique in a cohort of patients treated by operators from several countries 11 . However, in these previous experiences, AFR was performed without the use of a dedicated device, requiring advanced operator skills and prolonged procedural timing.…”

“…A subsequent multicentre experience confirmed the feasibility and safety of such a technique in a cohort of patients treated by operators from several countries. 11 However, in these previous experiences, AFR was performed without the use of a dedicated device, requiring advanced operator skills and prolonged procedural timing. A dedicated device may indeed facilitate guidewire re-entry to a distal true lumen and could be used by a less experienced operator.…”

Dual guidewire balloon for antegrade fenestration re‐entry: A welcome addition to the CTO operators' armamentarium

“…These transient fenestrations are engaged by a polymer jacketed wire to achieve re‐entry into the distal true lumen. In a multicenter study of 41 patients, AFR was successful in achieving CTO recanalization in 27 (69.5%) patients 3 …”