title: Predictors of restenosis following contemporary subintimal tracking and reentry technique: The importance of final TIMI flow grade.
abstract: OBJECTIVE
  To identify predictors of restenosis after recanalization of chronic total occlusions (CTOs) with the Subintimal Tracking And Reentry (STAR) technique.
  
  
  BACKGROUND
  STAR is associated with high rates of restenosis but the associated factors are not clear. Understanding the underlying mechanisms may be important to improve STAR outcomes and possibly other contemporary CTO recanalization techniques utilizing extensive subintimal dissection and stenting.
  
  
  METHODS
  We retrospectively analyzed 211 lesions that underwent a STAR procedure (between 2002 and 2013) with a final Thrombolysis in Myocardial Infarction (TIMI) flow grade 2 or 3. One-hundred and nineteen lesions that received drug eluting stents (DES) and underwent follow-up angiography were included in the final analysis.
  
  
  RESULTS
  Of the 119 lesions treated with DES following STAR, 75 restenoses were observed (63.0%). Utilizing multivariate analysis, TIMI flow grade in the recanalized artery following stent implantation at the end of the index procedure was the only independent predictor of restenosis.
  
  
  CONCLUSIONS
  Following recanalization of a CTO with STAR, final TIMI flow predicted future restenosis or reocclusion. As a bailout technique, STAR resulted in a high acute success rate with good safety and acceptable long-term results. When poor flow is observed following recanalization, and prior to stent implantation, a two-step strategy whereby a second procedure is performed at an interval to maximize coronary flow at the end of the procedure may be considered with the goal to reduce the risk of future restenosis or total vessel occlusion following STAR.
authors: Department of Interventional Cardiology, San Raffaele Scientific Institute, Milan, Italy.
authors: Mauro
authors: M
authors: Carlino
authors: Department of Interventional Cardiology, San Raffaele Scientific Institute, Milan, Italy.|Department of Interventional Cardiology, EMO-GVM Centro Cuore Columbus, Milan, Italy.
authors: Filippo
authors: F
authors: Figini
authors: Department of Interventional Cardiology, San Raffaele Scientific Institute, Milan, Italy.|Department of Interventional Cardiology, EMO-GVM Centro Cuore Columbus, Milan, Italy.|Department of Interventional Cardiology, Imperial College, London, United Kingdom.
authors: Neil
authors: N
authors: Ruparelia
authors: Department of Interventional Cardiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas.
authors: Barry F
authors: BF
authors: Uretsky
authors: Department of Interventional Cardiology, San Raffaele Scientific Institute, Milan, Italy.
authors: Cosmo
authors: C
authors: Godino
authors: Department of Interventional Cardiology, San Raffaele Scientific Institute, Milan, Italy.|Department of Interventional Cardiology, EMO-GVM Centro Cuore Columbus, Milan, Italy.
authors: Azeem
authors: A
authors: Latib
authors: Department of Interventional Cardiology, San Raffaele Scientific Institute, Milan, Italy.
authors: Letizia
authors: L
authors: Bertoldi
authors: Department of Interventional Cardiology, VA North Texas Health Care System, Dallas, Texas.|Department of Interventional Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas.
authors: Emmanouil
authors: E
authors: Brilakis
authors: Department of Interventional Cardiology, Presbyterian Hospital/Columbia University Medical Center, New York.
authors: Dimitri
authors: D
authors: Karmpaliotis
authors: Department of Interventional Cardiology, Careggi Hospital, Florence, Italy.
authors: David
authors: D
authors: Antoniucci
authors: Department of Interventional Cardiology, San Raffaele Scientific Institute, Milan, Italy.
authors: Alberto
authors: A
authors: Margonato
authors: Department of Interventional Cardiology, San Raffaele Scientific Institute, Milan, Italy.|Department of Interventional Cardiology, EMO-GVM Centro Cuore Columbus, Milan, Italy.
authors: Antonio
authors: A
authors: Colombo
mesh_terms: D000368:Aged; D001783:Blood Flow Velocity; D002908:Chronic Disease; D017023:Coronary Angiography; D003326:Coronary Circulation; D054059:Coronary Occlusion / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000628:therapy*; D023903:Coronary Restenosis / Q000000981:diagnostic imaging / Q000209:etiology* / Q000503:physiopathology / Q000517:prevention & control; D003331:Coronary Vessels / Q000000981:diagnostic imaging / Q000503:physiopathology*; D054855:Drug-Eluting Stents; D005260:Female; D006801:Humans; D007558:Italy; D008297:Male; D008875:Middle Aged; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects* / Q000295:instrumentation; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D016896:Treatment Outcome
keywords: TIMI flow; chronic total occlusion; coronary stenting; percutaneous coronary intervention; restenosis