Subadventitial stenting around occluded stents: A bailout technique to recanalize in-stent chronic total occlusions

Lorenzo Azzalini, Aris Karatasakis, James C. Spratt, Péter Tajti, Robert F. Riley, Luiz F. Ybarra, Stefan P. Schumacher, Susanna Benincasa, Barbara Bellini, Luciano Candilio, Satoru Mitomo, Peter Henriksen, Francisco Hidalgo, Leo Timmers, Adriaan O. Kraaijeveld, Pierfrancesco Agostoni, James Roy, David R. Ramsay, James C. Weaver, Paul KnaapenAlexander Nap, Boris Starcevic, Soledad Ojeda, Manuel Pan, Khaldoon Alaswad, William L. Lombardi, Mauro Carlino, Emmanouil S. Brilakis, Antonio Colombo, Stéphane Rinfret, Kambis Mashayekhi

Research output: Contribution to journalArticle

8 Scopus citations


Objectives: To evaluate the outcomes of subadventitial stenting (SS) around occluded stents for recanalizing in-stent chronic total occlusions (IS-CTOs). Background: There is little evidence on the outcomes of SS for IS-CTO. Methods: We examined the outcomes of SS for IS-CTO PCI at 14 centers between July 2011 and June 2017, and compared them to historical controls recanalized using within-stent stenting (WSS). Target-vessel failure (TVF) on follow-up was the endpoint of this study, and was defined as a composite of cardiac death, target-vessel myocardial infarction, and target-vessel revascularization. Results: During study period, 422 IS-CTO PCIs were performed, of which 32 (7.6%) were recanalized with SS, usually when conventional approaches failed. The most frequent CTO vessel was the right coronary artery (72%). Mean J-CTO score was 3.1 ± 0.9. SS 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 used in 59%. One patient (3.1%) suffered tamponade. Angiographic follow-up was performed in 10/32 patients: stents were patent in six cases, one had mild neointimal hyperplasia, and three had severe restenosis at the SS site. Clinical follow-up was available for 29/32 patients for a mean of 388 ± 303 days. The 24-month incidence of TVF was 13.8%, which was similar to historical controls treated with WSS (19.5%, P = 0.49). Conclusions: SS is rarely performed, usually as last resort, to recanalize complex IS-CTOs. It is associated with favorable acute and mid-term outcomes, but given the small sample size of our study additional research is warranted.

Original languageEnglish (US)
Pages (from-to)466-476
Number of pages11
JournalCatheterization and Cardiovascular Interventions
Issue number3
StatePublished - Sep 1 2018


  • chronic total occlusion
  • crushing
  • in-stent restenosis
  • percutaneous coronary intervention
  • subadventitial
  • subintimal

ASJC Scopus subject areas

  • Radiology Nuclear Medicine and imaging
  • Cardiology and Cardiovascular Medicine

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    Azzalini, L., Karatasakis, A., Spratt, J. C., Tajti, P., Riley, R. F., Ybarra, L. F., Schumacher, S. P., Benincasa, S., Bellini, B., Candilio, L., Mitomo, S., Henriksen, P., Hidalgo, F., Timmers, L., Kraaijeveld, A. O., Agostoni, P., Roy, J., Ramsay, D. R., Weaver, J. C., ... Mashayekhi, K. (2018). Subadventitial stenting around occluded stents: A bailout technique to recanalize in-stent chronic total occlusions. Catheterization and Cardiovascular Interventions, 92(3), 466-476.