Catheterization and Cardiovascular Interventions 85:391–392 (2015)

Editorial Comment How to Improve Your “STAR Quality” Barry F. Uretsky,1* MD, MSCAI, and Mauro Carlino,2 MD 1 Central Arkansas Veterans Health System, University of Arkansas for Medical Sciences, Little Rock, Arkansas 2 Division of Cardiology, San Raffaele Scientific Institute, Milan, Italy

Key Points

 The authors suggest that “bail-out” STAR subintimal dissection/re-entry technique may be improved by delaying of stenting after the initial procedure.  Deferring stenting for 2–3 months after the STAR procedure decreases the stent length and may decrease major adverse clinical outcomes.  Deferred stenting has similar incidence of target vessel revascularization as immediate stenting with the bailout STAR technique.

The Subintimal Tracking And Re-entry (STAR) technique holds an important historical place in the development of coronary chronic total occlusion (CTO) intervention. It was the first method to demonstrate that the subintimal space could be used to re-canalize the vessel. It is currently considered a “last-ditch bailout” technique because it is associated with high restenosis and re-occlusion rates and loss of side branches. Technically, re-entry site into the lumen is not controllable. The acute success of the technique did, however, provide the impetus and confidence for the development of other subintimal dissection/re-entry techniques where re-entry is more precise and possibly long-term results are improved. In this issue of CCI, Visconti et al. propose a modified approach to the management of the STAR patient [1]. During a nine-year period, these investigators treated 129 patients (7.3% of the total CTO patient cohort) with STAR as a bail-out procedure. The first 60 procedures had a stent(s) implanted during the initial procedure (the “Elective” group). In order to try to minimize the stent length, the authors then modified C 2015 Wiley Periodicals, Inc. V

their approach by not stenting initially and performing a second angiogram 2–3 months before definitive stenting was performed (the “Deferred” group). The main findings of their study was that the required stent length was significantly shorter in the Deferred group, primarily because the non-CTO dissected area healed in about two-thirds of cases. The Deferred group showed a lower combined rate of death and myocardial infarction than the Elective group (0% vs. 6.7%, P ¼ 0.049) and a trend to lower stent thrombosis rate (0% vs. 5%, P ¼ 0.10). Should we consider these data adequate to change our practice in the occasional case where STAR is used for bailout? The authors’ first finding that much of the dissection spontaneously heals in the non-CTO segment allowing a shorter stent length is not unexpected and is consistent with data from the pre-stent era where balloon angioplasty-induced dissections— even extensive ones—often healed with a consequent large patent lumen without angiographic evidence of dissection. Thus, if decreasing the stent length is a primary goal, stent deferral for a few months may be useful. However, it should be noted that by the time of the second angiography, a full 20% of successful STAR procedures had re-occluded. Further, more patients (32%) in the Deferred group required repeat revascularization than the Elective group (21.5%) though this difference was not statistically different. The second, more provocative study finding was that serious clinical events (death, MI, clinical stent thrombosis) were significantly reduced with the Deferred approach. There is reason to be cautious in interpreting the study results. First, the sample size was small and expectation of a true difference in clinical events is low. Thus, one must entertain the possibility that the results occurred by chance or were related to factors other than the modification in the STAR management. Since the modification occurred in the second half of Conflict of interest: Nothing to report. *Correspondence to: Barry F Uretsky, MD, 4300 West Seventh Street, Little Rock, AR 72205. E-mail: [email protected] Received 17 December 2014; Revision accepted 21 December 2014 DOI: 10.1002/ccd.25813 Published online 9 February 2015 in Wiley Online Library (wileyonlinelibrary.com)

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the study, procedural aspects other than stent deferral itself may have been improved such as more fastidious stent expansion, the availability of more potent antiplatelet agents, and increased duration of dual antiplatelet therapy which are associated with decreased stent thrombosis and stenosis. Of course, this hypothesis is speculative as are others that may be proposed but the unexpectedly large difference in events in a small sample size provokes caution in taking the authors’ modification to the clinic. Obviously, a large randomized trial (unlikely to occur) would help to settle the issue. The authors have suggested that it is the length of the subintimal stent that is the important factor in provoking the high restenosis and occlusion rate seen with the STAR technique. A recent study from a Japanese registry may be instructive in this regard. In the Deferred group in the current study, the length of stent implanted was 22 6 33 mm. There was a 32% incidence of clinically driven target vessel revascularization (TVR). In the J-FACTOR registry, using both antegrade and retrograde techniques and documentation of subintimal passage with intravascular ultrasound (IVUS), the stent length was longer at 61 6 23 mm [2]. Despite this longer length, clinically driven TVR was much lower at 12.9%. Although comparing the results of different studies can be treacherous, the much higher clinically driven TVR with STAR than other dissection/re-entry methods suggest that factors other than the length of the subintimal stent may be responsible for the worsened clinical outcome.

It is the experience of most CTO operators that at the end of the STAR procedure, even with normalized antegrade flow and stenting, there are angiographically apparent dissections and other evidence of vessel trauma. This final appearance contrasts with newer antegrade and retrograde procedures where a successful result often provides a near pristine angiographic appearance at the CTO and peri-CTO sites. This observation suggests that residual vessel trauma may be more likely the culprit that provokes vessel thrombosis and occlusion than the length of the subintimal stent length itself. The authors have provided valuable data regarding the intermediate angiographic outcome of the STAR technique when it is limited to balloon angioplasty without stenting. Whether their modification in management will truly improve “STAR quality” is less certain. The authors are to be congratulated on provoking the interested reader to consider newer ways to improve outcomes with this “standard” dissection/reentry bailout technique. REFERENCES 1. Visconti G, Focaccio A, Donahue M, Briguori C. Elective versus deferred stenting following subintimal recanalization of coronary chronic total occlusion. Cathet Cardiovasc Interv 2014;85:382–390. 2. Muramatsu T, Tsuchikane E, Oikawa Y, Otsuji S, Fujita T, Ochiai M, Kawasaki T, Abe M, Sakurada M, Kishi K. Incidence and impact on midterm outcome of controlled subintimal tracking in patients with successful recanalisation of chronic total occlusions: J-PROCTOR registry. Eurointervention 2014;10:681–688.

Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).

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