Aris Karatasakis1, Barbara A Danek1, Judit Karacsonyi2, Lorenzo Azzalini3, Mauro Carlino3, Stéphane Rinfret4, Minh Vo5, Bavana V Rangan2, M N Burke6, Subhash Banerjee2, Emmanouil S Brilakis7. 1. Department of Cardiology, UT Southwestern Medical Center and VA North Texas Health Care System, Dallas, TX, United States; Department of Internal Medicine, Rutgers New Jersey Medical School, Newark, NJ, United States. 2. Department of Cardiology, UT Southwestern Medical Center and VA North Texas Health Care System, Dallas, TX, United States. 3. Division of Interventional Cardiology, San Raffaele Hospital, Milan, Italy. 4. Division of Interventional Cardiology, Quebec Heart and Lung Institute and McGill University Health Centre, Montreal, Canada. 5. Division of Interventional Cardiology, Mazankowski Alberta Heart Institute, Edmonton, Canada. 6. Division of Interventional Cardiology, Minneapolis Heart Institute, Minneapolis, MN, United States. 7. Department of Cardiology, UT Southwestern Medical Center and VA North Texas Health Care System, Dallas, TX, United States; Division of Interventional Cardiology, Minneapolis Heart Institute, Minneapolis, MN, United States. Electronic address: emmanouil.brilakis@allina.com.
Abstract
BACKGROUND: Some reports have demonstrated increased risk with subadventitial chronic total occlusion (CTO) crossing, whereas others suggest equipoise between subadventitial and intraplaque crossing techniques. We sought to clarify the effect of subadventitial lesion crossing on mid-term outcomes of CTO percutaneous coronary intervention (PCI). METHODS: We conducted a systematic review and meta-analysis of studies reporting post-discharge outcomes after CTO PCI performed via subadventitial vs. intraplaque approaches. RESULTS: Five studies comprising a total of 2,539 patients were included. Compared with intraplaque crossing (n=1,654, 65.1%), subadventitial cases (n=885, 34.9%) had a higher J-CTO score (2.9±1.2 vs. 1.6±1.2, p<0.001), and required significantly longer stent lengths (difference in means: 19.66 mm [95% confidence interval (CI), 11.23 to 28.08]; p<0.001). At a median follow-up of 12.0months, subadventitial CTO crossing was associated with a higher overall rate of target vessel revascularization (TVR, crude rate, 11.5% vs. 7.6%, odds ratio [OR]: 2.19 [95% CI, 1.62 to 2.95]; p<0.001); the risk was higher in studies of extensive compared with limited dissection and re-entry techniques (OR: 3.46 [95% CI: 2.24 to 5.36] vs. 1.52 [95% CI, 0.94 to 2.46], pinteraction=0.013). The rates of stent thrombosis, myocardial infarction, and cardiovascular mortality did not vary significantly between subadventitial and intraplaque crossing. CONCLUSIONS: CTOs treated with subadventitial crossing were significantly more complex as compared with CTOs treated with intraplaque crossing. Extensive subadventitial crossing techniques were associated with higher TVR rates as compared with limited techniques, supporting the important role of limited techniques in the treatment of complex CTOs. Published by Elsevier B.V.
BACKGROUND: Some reports have demonstrated increased risk with subadventitial chronic total occlusion (CTO) crossing, whereas others suggest equipoise between subadventitial and intraplaque crossing techniques. We sought to clarify the effect of subadventitial lesion crossing on mid-term outcomes of CTO percutaneous coronary intervention (PCI). METHODS: We conducted a systematic review and meta-analysis of studies reporting post-discharge outcomes after CTO PCI performed via subadventitial vs. intraplaque approaches. RESULTS: Five studies comprising a total of 2,539 patients were included. Compared with intraplaque crossing (n=1,654, 65.1%), subadventitial cases (n=885, 34.9%) had a higher J-CTO score (2.9±1.2 vs. 1.6±1.2, p<0.001), and required significantly longer stent lengths (difference in means: 19.66 mm [95% confidence interval (CI), 11.23 to 28.08]; p<0.001). At a median follow-up of 12.0months, subadventitial CTO crossing was associated with a higher overall rate of target vessel revascularization (TVR, crude rate, 11.5% vs. 7.6%, odds ratio [OR]: 2.19 [95% CI, 1.62 to 2.95]; p<0.001); the risk was higher in studies of extensive compared with limited dissection and re-entry techniques (OR: 3.46 [95% CI: 2.24 to 5.36] vs. 1.52 [95% CI, 0.94 to 2.46], pinteraction=0.013). The rates of stent thrombosis, myocardial infarction, and cardiovascular mortality did not vary significantly between subadventitial and intraplaque crossing. CONCLUSIONS: CTOs treated with subadventitial crossing were significantly more complex as compared with CTOs treated with intraplaque crossing. Extensive subadventitial crossing techniques were associated with higher TVR rates as compared with limited techniques, supporting the important role of limited techniques in the treatment of complex CTOs. Published by Elsevier B.V.
Entities:
Keywords:
Chronic total occlusion; Dissection and re-entry; Outcomes; Percutaneous coronary intervention; Subadventitial; Subintimal
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