1. Subintimal Tracking and Reentry for CTO STAR Method
Craig A. Thompson, M.D., MMSc.
Director, Invasive Cardiology and Vascular Medicine
Yale University School of Medicine/Yale New Haven Hospital
Executive Director, Yale-University College London Cardiovascular Device Development Program
Consultant (Hon) Heart Hospital, London and London Chest Hospital

2. Craig A. Thompson, MD Consulting Fees Abbott Vascular Bridgepoint
Terumo
Volcano
I intend to reference off label or unapproved uses of drugs or devices in my presentation.
I intend to discuss DES, guidewires, PTCA balloons/catheters in CTO

3. Subintimal Tracking and Reentry (STAR) rationale and historical perspective
Alternative technique for distal true lumen access
Adaptation of technique in peripheral CTO intervention
Devascularized vessel in CTO = devitalized tissue at media
Natural dissection plane
Used by surgeons for endarterectomy
Reentry
?Path of least resistance in distal “normal” vessel toward lumen
Smaller distal vessel less likely to propagate dissection

4. Antegrade Dissection and Reentry STAR method

5. Art of the Knuckle Wire

6. Knuckle wire IVUS

7. Subintimal Tracking and Reentry (STAR) Patient Selection
Failure with conventional wire strategies
No retrograde opportunity
Relatively healthy distal vessel beyond CTO
Minimal important branches in shear/dissection zone (RCA, OM)
Strong clinical indication
This is final measure, not first measure
Better methods have been developed!

8. Subintimal Tracking and Reentry (STAR) technique
Supportive 8Fr guide
Create or use existing dissection in proximal CTO (Miracle, Confianza, etc.)
1.5mm balloon into track
Fielder XT/Whisper/Pilot 50 with tight “J” tip/”umbrella tip”
Advance with balloon support, avoid spinning wire if possible
May need pilot 150, 200 for proximal
Use softest wire possible for distal (whisper)
Reentry

9. Antegrade Dissection and Reentry
Minimal subadventitial space
Enlarged subadventitial space
Occlusion
Occlusion

10. Subintimal Tracking and Reentry (STAR) Side branch rescue
Runoff is key to durability
Miracle/Confianza – parallel wire
Mini-STAR
Wire in SB ostium
1.5 balloon to ostium
Exchange for Whisper “J” tip

11. Subintimal Tracking and Reentry (STAR) Tips
Stiffer polymer wire (“J”) proximally if needed but always softer distally
“J-bend” ~ < media-to-media diameter
Runoff vessels are key
Don’t lose true lumen distal branch, multiple wires if necessary
PTCA pre-stent conservative size, pressures <12 ATM
Bifurcation stenting only if absolutely necessary
SB dissections may be OK
DES
Consider angiographic follow-up

12. Subintimal Tracking and Reentry (STAR)

13. Subintimal Tracking and Reentry (STAR)

14. Subintimal Tracking and Reentry (STAR) Complications
Perforation
Side branch loss
Runoff Vessel Loss
Unpredictable dissection
Relatively high restenosis
Failure

15. STAR Technique baseline demographics
112 patients, 119 lesions
CTO Length
Criterion for STAR
Courtesy M Carlino, A Colombo

16. STAR Technique acute outcome and complications (112 pt./119 lesion)
Recanalization with Angiographic success in 103/119 lesions (86.6%)
4 (3.4%) Dissection limiting procedure
1 acute thrombosis
5 (4.2%) wire perforation limiting procedure
3 (2.5%) vessel rupture [3 PTFE stent]
Courtesy M Carlino, A Colombo

17. STAR Technique MACE In Hospital Death 0 CABG 0 Non Q MI 16/112 (14%)
6 Month Follow-up
Death 1/112 (noncardiac)
CABG 1/112
AMI 0
Courtesy M Carlino, A Colombo

18. STAR Technique Angiographic Follow-up 77/112 (69% eligible pt., 6.2+4.1 months)
Restenosis 38/77 (49.4%)
TLR 36/119 (30.2%) %
P<0.008
P<0.01
Courtesy M Carlino, A Colombo

19. STAR guided by contrast injection
Carlino M, et al. CCI 2008

20. Subintimal Tracking and Reentry STAR coronary technique Conclusions
Relatively safe and effective alternative method to cross coronary CTO
Conventional antegrade failure, poor retrograde option
Learning curve
Most appropriate for “conduit” vessels (RCA/OM)
DES and runoff vessels appear to be important determinants of durability
Better methods and technologies have been developed for dissection/redirection and reentry