Subadventitial crossing and crushing to recanalize in-stent chronic total occlusions: A multicenter registry
Azzalini L, Karatasakis A, Spratt J, Tajti P, Ybarra L, Benincasa S, Bellini B, Candilio L, Hidalgo F, Timmers L, Kraaijeveld A, Agostoni P, Roy J, Ramsay D, Weaver J, Knaapen P, Starcevic B, Ojeda S, Pan M, Alaswad K, Lombardi W, Rinfret S, Carlino M, Brilakis E, Colombo A, Mashayekhi K. Subadventitial crossing and crushing to recanalize in-stent chronic total occlusions: A multicenter registry. J Am Coll Cardiol. 2017;70(18):B11.
J Am Coll Cardiol
BACKGROUND Crossing chronic total occlusions (CTOs) due to instent restenosis (ISR) can sometimes be achieved with subadventitial crossing and crushing (SC+C) of the occluded stent, when conventional approaches have failed. We aimed at evaluating the outcomes of this technique. METHODS We examined the acute and follow-up outcomes of ISR-CTO percutaneous coronary intervention (PCI) performed at 14 centers between July 2011 and June 2017. Target-vessel failure (TVF) was defined as a composite of cardiac death, target-vessel myocardial infarction (TV-MI), and ischemia-driven target-vessel revascularization (TVR). RESULTS A totalof 422 in-stent CTO PCIs were performed during the study period, of which 32 (7.6%) were recanalized with SC+C. Class III-IV angina was present in 50% of patients. The most frequent CTO vessel was the right coronary artery (72%), and mean J-CTO score was 3.1±0.9. SC+C was performed after failure of other crossing techniques in all but 2 patients. The CrossBoss catheter was used in 38%. SC+C was antegrade in 53%, and retrograde in 47%. Part of the occluded stent was crushed in 37%, while the whole stent was crushed in 63%. Intravascular imaging was performed in 59%. Total newly implanted stent length was 106±35 mm, contrast volume was 305±144 ml, and fluoroscopy time was 79±45 min. One patient (3.1%) suffered tamponade. Angiographic followup was performed in 10/32 patients at amean of 148±123 days: The stents were patent in 6 cases, 1 had mild ISR, and 3 had severe ISR at the site of SC+C. Clinical follow-up was available for 29/32 patients for amean of 388±303 days. The incidence of TVF was 20.7% (n=6), including cardiac death 3.4% (n=1, unrelated to SC+C), TV-MI 3.4% (n=1, due to stent thrombosis proximal to the SC+C site), and TVR 20.7% (n=6). CONCLUSION This is the first systematic study of SC+C for treating CTOs due to ISR. This technique is rarely performed, usually as last resort, torecanalize complex occlusions. SC+C is associated with favorable acute and mid-term outcomes, but given the small sample size of our study additional research is warranted.