Impact of crossing strategy on midterm outcomes following percutaneous revascularisation of coronary chronic total occlusions

Aims: The aim of the present study was to compare the midterm clinical outcomes of patients undergoing successful chronic total occlusion (CTO) percutaneous coronary intervention (PCI) according to the crossing technique used, in a large multicentre registry. Methods and results: We compiled a multicentre registry of consecutive patients undergoing successful CTO PCI. Patients were divided into three groups: true-to-true (TTT) approach, modern dissection/re-entry (DR) techniques (CrossBoss/Stingray, reverse CART), and old DR techniques (LAST, STAR, CART). Cox regression was used to identify independent predictors of major adverse cardiac events (MACE: cardiac death, myocardial infarction and target vessel revascularisation). We included 924 patients (TTT, n=571; modern DR, n=258; old DR, n=95). Patients in both DR groups had a higher prevalence of comorbidities, angiographic and procedural complexity. The 12-month MACE rate was higher in old DR (22.1%) than in modern DR (8.9%) and TTT (9.1%, p<0.001). Old (hazard ratio [HR] 2.02, 95% confidence interval [CI]: 1.12 to 3.61, p=0.02) but not modern (HR 0.98, 95% CI: 0.54 to 1.79, p=0.96) DR techniques were associated with a higher adjusted risk of MACE compared to TTT. Conclusions: The use of old but not modern DR techniques was associated with a higher risk of MACE. Therefore, CrossBoss/Stingray and reverse CART might be considered as first-line strategies for antegrade and retrograde DR-based CTO PCI, respectively.