title: Coronary chronic total occlusions: mid-term comparison of clinical outcome following the use of the guided-STAR technique and conventional anterograde approaches.
abstract: OBJECTIVE
  There are limited data on the mid-term safety following the use of the guided-subintimal tracking and re-entry (guided-STAR) technique for the treatment of chronic total occlusions (CTO) and concerns have arisen about a potential increased risk of stent thrombosis (ST).
  
  
  OBJECTIVE
  The aim of this study was to evaluate the mid-term safety in terms of cardiac death and ST after recanalization using the contrast guided-STAR technique when compared to conventional anterograde CTO recanalization (CA-CTO).
  
  
  RESULTS
  This retrospective study analyzed 355 consecutive patients with successful angiographic recanalization (residual stenosis <20% and TIMI flow grade ≥2) of CTO lesion. Seventy-four (20.8%) underwent guided-STAR and 281 (79.2%) had CA-CTO. Survival rates were estimated using the Kaplan-Meier method. Compared to CA-CTO patients, the rate of the following clinical, angiographic, and procedural characteristics were significantly higher in guided-STAR patients: hypercholesterolemia (84 vs. 67%, P = 0.004), previous CABG (41.3 vs. 15.7%, P < 0.0001), three-vessel disease, (62.7 vs. 47%, P = 0.019), right coronary artery CTO (62.7 vs. 41.6%, P = 0.002), stent length (68.15 vs. 54.05 mm, P < 0.0001). A drug-eluting stent was implanted in the majority of cases (89.2% guided-STAR vs. 93.5% CA-CTO). At a median follow-up of 779 days (IQR 495-1035), there were no significant differences in cardiac survival (97.2 vs. 97.5%, Log-rank P = 0.912) and cumulative ARC ST rates (2.8 vs. 1.8%, Log-rank P = 0.610) for guided-STAR and CA-CTO patients, respectively. The rate of restenosis was significantly higher in the guided-STAR group compared to the CA-CTO group (54 vs. 30%, Log-rank P < 0.0001). The adjusted Cox proportional-hazard analysis for procedural technique showed that the only significant independent predictor of restenosis was the stent length (HR, 1.017; 95% CI, 1.008-1.027; P < 0.0001).
  
  
  CONCLUSIONS
  At mid-term follow-up, the guided-STAR was not inferior to CA-CTO in terms of safety. The only significant independent predictor of restenosis was the stent length.
authors.affiliation: Interventional Cardiology Unit, San Raffaele Institute, Milan, Italy. cosmogodino@gmail.com
authors.forename: Cosmo
authors.initials: C
authors.lastname: Godino
authors.forename: Azeem
authors.initials: A
authors.lastname: Latib
authors.forename: Fotios I
authors.initials: FI
authors.lastname: Economou
authors.forename: Rasha
authors.initials: R
authors.lastname: Al-Lamee
authors.forename: Alfonso
authors.initials: A
authors.lastname: Ielasi
authors.forename: Giorgio
authors.initials: G
authors.lastname: Bassanelli
authors.forename: Filippo
authors.initials: F
authors.lastname: Figini
authors.forename: Alaide
authors.initials: A
authors.lastname: Chieffo
authors.forename: Matteo
authors.initials: M
authors.lastname: Montorfano
authors.forename: Antonio
authors.initials: A
authors.lastname: Colombo
authors.forename: Mauro
authors.initials: M
authors.lastname: Carlino
mesh_terms: D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods* / Q000401:mortality; D016009:Chi-Square Distribution; D002908:Chronic Disease; D017023:Coronary Angiography; D054059:Coronary Occlusion / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D023903:Coronary Restenosis / Q000209:etiology; D054855:Drug-Eluting Stents; D005260:Female; D006801:Humans; D007558:Italy; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D011474:Prosthesis Design; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013927:Thrombosis / Q000209:etiology; D013997:Time Factors; D016896:Treatment Outcome