Antegrade dissection and re-entry for chronic total occlusions

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Antegrade dissection and re-entry for chronic total occlusions

Antegrade dissection and re-entry for chronic total occlusions: Opening up of chronic total occlusions (generally more than 3 months old) is always challenging. While attempting to wire a chronic total occlusion (CTO), the wire can go subintimally and then renter the true lumen distally. Unless there is guidance with intravascular ultrasound (IVUS) or optical coherence tomography (OCT), it is almost a blind try.

In the technique known as sub-intimal tracking and re-entry (STAR) technique, a knuckled wire was passed [1]. But this produced an uncontrolled re-entry, sometimes very distally near a bifurcation. Stenting then would result in run off into one terminal branch. Hence long term results were not good [2]. There were other techniques like limited antegrade sub-intimal tracking (LAST), which also had significant limitations [3].

Because of the unreliability of conventional antegrade dissection and re-entry (ADR) techniques, special hardware have been developed, to improve results. They are the CrossBoss and Stingray system (Boston Scientific, Marlborough, MA, USA) [3]. CrossBoss catheter has a 1 mm rounded tip which can be used as a blunt dissection tool. In 10% of cases, it can track through the intimal plaque and re-enter the distal true lumen. It can also be used to produce a controlled dissection in the sub intimal space so that the Stingray balloon can be delivered just beyond the distal cap of the CTO. These devices thus allow a focused puncture so that all distal branches get adquate blood flow. This technique has redproducibility and predictability of the re-entry site, unlike the older techniques. But the hardware is more expensive.

References

  1. Antonio Colombo, Ghada W Mikhail, Iassen Michev, Ioannis Iakovou, Flavio Airoldi, Alaide Chieffo, Renata Rogacka, Mauro Carlino, Matteo Montorfano, Giuseppe M Sangiorgi, Nicola Corvaja, Goran Stankovic. Treating Chronic Total Occlusions Using Subintimal Tracking and Reentry: The STAR Technique. Catheter Cardiovasc Interv. 2005 Apr;64(4):407-11.
  2. Renato Valenti, Ruben Vergara, Angela Migliorini, Guido Parodi, Nazario Carrabba, Giampaolo Cerisano, Emilio Vincenzo Dovellini, David Antoniucci. Predictors of Reocclusion After Successful Drug-Eluting Stent-Supported Percutaneous Coronary Intervention of Chronic Total Occlusion. J Am Coll Cardiol. 2013 Feb 5;61(5):545-50.
  3. Simon J Walsh, Claudia Cosgrove, James C Spratt, Colm G Hanratty. A Technical Focus on Antegrade Dissection and Re-entry for Coronary Chronic Total Occlusions: A Practice Update for 2019. Korean Circ J. 2019 Jul;49(7):559-567.