Limited antegrade subintimal tracking (LAST)

Limited antegrade subintimal tracking (LAST)

Subintimal tracking is often resorted to cross chronic total occlusions. A relatively stiff wire is pushed gradually till it forms a knuckle or loop subintimally beyond the distal end of the lesion. After that re-entry is achieved using a wire with an acute distal bend [1].

In a case reported, by Michael TT et al [1], Fielder XT wire was advanced until a knuckle formed at its tip, which crossed into the subintimal space of the chronic total occlusion. Then a Confianza Pro 12 guidewire was used to re-enter the distal true lumen. It may be noted that an initial attempt with a Confianza Pro 12 had failed to cross the chronic total occlusion. Occasionally the help of a Venture catheter is needed for Confianza Pro 12 to cross the lesion by the LAST technique.

A study published in November 2022 analyzed 2,177 CTO PCIs performed using antegrade dissection and re-entry in the PROGRESS-CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention). In the registry involving 39 centers. ADR was attempted in 1,465 cases (67.3%). In that report usage of LAST was noted in 11.1% of antegrade re-entry CTO PCI cases. Authors concluded that LAST was associated with lower procedural success on multivariable analysis, indicating only a limited role for LAST in contemporary CTO PCI [2].

References

1. Michael TT, Papayannis AC, Banerjee S, Brilakis ES. Subintimal dissection/reentry strategies in coronary chronic total occlusion interventions. Circ Cardiovasc Interv. 2012;5:729-38.
2. Karacsonyi J, Kostantinis S, Simsek B, Alaswad K, Karmpaliotis D, Kirtane A, Jaffer F, Choi JW, Koutouzis M, Tsiafoutis I, Kandzari DE, Poommipanit P, Khatri JJ, Elbarouni B, Gorgulu S, ElGuindy A, Abi Rafeh N, Goktekin O, Ungi I, Rangan BV, Sandoval Y, Allana S, Burke MN, Brilakis ES. Use of the Limited Antegrade Subintimal Tracking Technique in Chronic Total Occlusion Percutaneous Coronary Intervention. JACC Cardiovasc Interv. 2022 Nov 28;15(22):2284-2293. doi: 10.1016/j.jcin.2022.08.052. PMID: 36423972.