One‐year outcomes after successful chronic total occlusion percutaneous coronary intervention: The impact of dissection re‐entry techniques

Abstract

We aimed to determine clinical outcomes 1 year after successful chronic total occlusion (CTO) PCI and, in particular, whether use of dissection and re-entry strategies affects clinical outcomes. Hybrid approaches have increased the procedural success of CTO percutaneous coronary intervention (PCI) but longer-term outcomes are unknown, particularly in relation to dissection and re-entry techniques. Data were collected for consecutive CTO PCIs performed by hybrid-trained operators from 7 United Kingdom (UK) centres between 2012 and 2014. The primary endpoint (death, myocardial infarction, unplanned target vessel revascularization) was measured at 12 months along with angina status. One-year follow up data were available for 96% of successful cases (n = 805). In total, 85% of patients had a CCS angina class of 2-4 prior to CTO PCI. Final successful procedural strategy was antegrade wire escalation 48%; antegrade dissection and re-entry (ADR) 21%; retrograde wire escalation 5%; retrograde dissection and re-entry (RDR) 26%. Overall, 47% of CTOs were recanalized using dissection and re-entry strategies. During a mean follow up of 11.5 ± 3.8 months, the primary endpoint occurred in 8.6% (n = 69) of patients (10.3% (n = 39/375) in DART group and 7.0% (n = 30/430) in wire-based cases). The majority of patients (88%) had no or minimal angina (CCS class 0 or 1). ADR and RDR were used more frequently in more complex cases with greater disease burden, however, the only independent predictor of the primary endpoint was lesion length. CTO PCI in complex lesions using the hybrid approach is safe, effective and has a low one-year adverse event rate. The method used to recanalize arteries was not associated with adverse outcomes. © 2017 Wiley Periodicals, Inc.

Does the end justify the means? The contemporary role of dissection/re‐entry strategies for recanalization of coronary chronic total occlusions

“…In the current issue of the Journal, Wilson et al analyzed one‐year outcomes after 805 successful CTO percutaneous coronary intervention (PCIs). Subadventitial techniques were the final successful strategy in 375 (47%) cases . Consistent with previous reports, subadventitial techniques were utilized in more complex lesions (J‐CTO score 3.2 ± 1.2 vs. 1.8 ± 1.3, P = 0.001), and resulted in longer stent lengths and worse procedural efficiency metrics.…”

“…However, there is the option of becoming an “antegrade only” CTO operator, by using antegrade but not retrograde dissection/re‐entry. The third question is “If during antegrade crossing attempts the guidewire enters the subintimal space should I continue antegrade wire escalation (e.g., using the parallel wire technique) or should I change to dissection/re‐entry?” This question remains unanswered: using dissection/re‐entry may improve the efficiency of the procedure, but may result in higher cost, longer stent length, side branch loss, and potentially higher restenosis rates (although the difference did not reach statistical significance in the study by Wilson et al ). On the other hand, continued wire crossing attempts could create a subintimal hematoma potentially hindering subsequent re‐entry attempts.…”

The impact of dissection and re-entry versus wire escalation techniques on long-term clinical outcomes in patients with chronic total occlusion lesions following percutaneous coronary intervention: An updated meta-analysis

“…Eleven studies with 4,260 patients were included, and low heterogeneity was found (I 2 = 26.50%, p = 0.192; Fig. 2D) [11,[14][15][16][17][18][19][20][21][22]24]. The data revealed significant differences between the two groups with regard to TVR (RR = 1.61, 95% CI: 1.29-2.01; Fig.…”

“…The CTO length was significantly longer in patients with subintimal DR techniques, when compared with conventional WE crossing (SMD: 0.64, 95% CI: 0.31-0.97, p < 0.001; I 2 = 83.4%, p < 0.001; Fig. 3D) [14,16,17,19,21].…”

“…The remaining 65 studies were assessed by reading the full texts. Eventually, 12 cohort studies were included in qualitative synthesis and meta-analysis [11,[14][15][16][17][18][19][20][21][22][23][24]. The flow diagram of the study selection process is presented in Figure 1.…”