Subadventitial crossing and crushing to recanalize in-stent chronic total occlusions: A multicenter registry

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Conference Proceeding

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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.





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