Dissection and Re-Entry Techniques and Longer-Term Outcomes Following Successful Percutaneous Coronary Intervention of Chronic Total Occlusion Stéphane Rinfret, MD, SM*, Henrique Barbosa Ribeiro, MD, Can Manh Nguyen, MD, Luis Nombela-Franco, MD, Marina Ureña, MD, and Josep Rodés-Cabau, MD New techniques involving dissection of the subintimal space and re-entry into the true lumen increase success rates in chronic total occlusion (CTO) percutaneous coronary intervention (PCI). However, their long-term safety and efficacy were unknown. This study included a series of consecutive patients who underwent CTO PCI. All patients who did not present events were contacted 12 to 18 months after their PCI. The combined incidence of cardiac death, myocardial infarction, ischemia-driven target-vessel revascularization (TVR), or reocclusion was assessed as our primary outcome. From January 2010 to January 2013, of 212 CTOs treated in our CTO program, 192 (91%) were successfully opened (in 179 patients). Follow-up data were available for 187 CTOs (97.4%), with 82 (44%) that were opened with dissection re- entry and 105 (56%) with conventional wire escalation techniques. At a median follow-up of 398 days, the primary outcome occurred in 18 of 179 CTOs treated (10.7%), driven by TVR. No patient died from cardiac causes. Eleven CTOs (15.2%) treated with dissection re-entry versus 7 CTOs (7.3%) treated with wire escalation presented with the primary outcome (p [ 0.17). With multivariate adjustment, dissection re-entry techniques had no significant impact on outcomes. However, treatment of an in-stent occlusion was independently associated with TVR (hazards ratio >6.0, p <0.001). In conclusion, dissection re-entry techniques have minimal impact on long-term outcomes after CTO PCI, which are favorable in most patients. However, treatment of an in-stent occlusion and use of sirolimus-eluting stent were predictors of subsequent adverse outcomes. Ó 2014 Elsevier Inc. All rights reserved. (Am J Cardiol 2014;-:-e-) Better outcomes have been associated with successful versus failed recanalization of chronic total occlusion (CTO) in observational studies 1 and with drug-eluting stent (DES) compared with bare-metal stent implantation, 2 especially with newer-generation DESs versus the first generation 3 when used for CTOs. However, the impact of the tech- nique used to open the CTO on longer-term outcomes after successful recanalization and DES implantation is largely unknown. Dissection and re-entry techniques (DARTs), performed either from the retrograde 4 or the anterograde approach, with wires or with novel devices such as the CrossBoss and Stingray (Boston Scientific) catheters, 5 improve technical success while maintaining low compli- cation rates. 6e9 Such novel techniques invariably result in subintimal DES implantation. To date, only 2 studies spe- cifically assessed long-term outcomes of DESs implanted in the subintimal space. 10,11 Both studies reported mitigated results, which raises questions on the safety of subintimal re- entry techniques. No study has to date evaluated outcomes including anterograde and retrograde DART, both resulting in subintimal or subadventitial stenting. The purpose of the study was therefore to examine the longer-term outcomes of patients who underwent successful CTO percutaneous cor- onary intervention (PCI) in our program, compare the effect of DART on outcomes, and assess predictors of long-term events. Methods A total of 248 consecutive CTO PCI procedures were performed by 1 operator (SR) from January 2010 to January 2013 inclusively. Of these, 36 procedures were performed outside our institution and were excluded of follow-up (FU) analysis. Baseline, procedural, and hospitalization data were prospectively collected and entered into a dedicated database. Data collection was approved by our institutional review committee as part of the Recherche Évaluative en Cardiologie InTervenionnelle registry, and subjects provided signed informed consent for long-term telephone FU. Events such as cardiac death, myocardial infarction (MI), target-vessel revascularization (TVR), or target-vessel reocclusion were collected when patients were readmitted in our institution. If not, they were systematically contacted 12 to 18 months after their PCI by 1 trained research assistant who was not aware of procedural data. During those telephone calls, need for repeat revascularization in another hospital, need for emergency department visit for angina, clinical status as defined by the Canadian Cardiovascular Society class, use of nitroglycerin (none, daily, weekly, or less than weekly), and frequency of angina (none, daily, weekly, or less than weekly) within the last 4 weeks were assessed. Multidisciplinary Department of Cardiology, Institut universitaire de cardiologie et de pneumologie de Québec (Quebec Heart & Lung Institute), Laval University, Quebec City, Quebec, Canada. Manuscript received June 5, 2014; revised manuscript received and accepted July 18, 2014. See page 7 for disclosure information. *Corresponding author: Tel: (418) 656-8711; fax: (418) 656-4544. E-mail address: stephane.rinfret@criucpq.ulaval.ca (S. Rinfret). 0002-9149/14/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. www.ajconline.org http://dx.doi.org/10.1016/j.amjcard.2014.07.067