Subintimal Tracking and
Reentry
Indications, Technique, Acute and Late
Success
Craig A. Thompson, M.D., MMSc.
Director, Invasive Cardiology and Vascular
Medicine
Yale University School of Medicine
New Haven, CT USA
DISCLOSURES
Craig A. Thompson, MD
Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or
affiliation with the organization(s) listed below.
Affiliation/Financial Relationship
Company
Grant/Research Support
Abbott Vascular, Boston Scientific,
Cordis
Consulting Fees/Honoraria
Abbott Vascular , Bridgepoint
Medical, Medtronic, Sanofi-Aventis
Major Stock Shareholder/Equity
None
Royalty Income
None
Ownership/Founder
None
Intellectual Property Rights
None
Other Financial Benefit
None
Disclosure Statement of Financial Interest
Within the past 12 months, I or my spouse/partner have had a
financial interest/arrangement or affiliation with the organization(s)
listed below.
Affiliation/Financial Relationship
Company
Grant/Research Support
Abbott Vascular, Boston Scientific,
Cordis
Consulting Fees/Honoraria
Abbott Vascular , Bridgepoint
Medical, InfraRedx,
Medtronic, Sanofi-Aventis
Major Stock Shareholder/Equity
None
Royalty Income
None
Ownership/Founder
None
Intellectual Property Rights
None
Other Financial Benefit
None
Subintimal Tracking and Reentry (STAR)
rationale
• 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

Anterograde Dissection and Reentry
STAR
Subintimal Tracking and Reentry (STAR)
Patient Selection
• Failure with conventional wire
•
•
•
•
•
strategies (parallel, see-saw)
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
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
Antegrade Dissection and Reentry
Minimal
subadventitial
space
Occlusion
Enlarged
subadventitial
space
Occlusion
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

Mini-STAR
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
Subintimal Tracking and Reentry
(STAR)
Subintimal Tracking and Reentry
(STAR)
Subintimal Tracking and Reentry (STAR)
Complications
•
•
•
•
•
•
Perforation
Side branch loss
Runoff Vessel Loss
Unpredictable dissection
Relatively high restenosis
Failure
STAR Technique
baseline demographics
112 patients, 119 lesions
6.7
28.6
80
64.7
70
<10mm
10-20mm
>20mm
60
50
RCA
LCx/OM
LAD/diag
40
30
CTO Length
20
10
0
Vessel Distribution
36
Crossover
Reattempt
64
Criterion for STAR
Courtesy M Carlino, A Colombo
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
3 (2.5%) vessel rupture [3
PTFE stent]
Courtesy M Carlino, A Colombo
1 acute thrombosis
5 (4.2%) wire
perforation limiting
procedure
STAR Technique
MACE
• In Hospital



Death
CABG
Non Q MI
0
0
16/112 (14%)
• 6 Month Follow-up



Death
CABG
AMI
Courtesy M Carlino, A Colombo
1/112 (noncardiac)
1/112
0
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%)
80
75
70
58
60
50
% 40
30
40
26
P<0.008
20
P<0.01
10
0
Restenosis
Courtesy M Carlino, A Colombo
TLR
BMS
DES
STAR guided by contrast injection
Carlino M, et al. CCI 2008
Subintimal Tracking and Reentry
STAR coronary technique
Conclusions
• Relatively safe and effective alternative
method to cross coronary CTO

Conventional anterograde failure, poor
retrograde option
• Learning curve
• Most appropriate for “conduit” vessels
(RCA/OM)
• DES and runoff vessels appear to be
important determinants of durability
Limited Antegrade Subintimal
Tracking
the LAST technique
Craig A. Thompson, M.D., MMSc.
Director, Invasive Cardiology and Vascular
Medicine
Yale University School of Medicine
New Haven, CT USA
Limitations of the STAR Method
introduction of Limited Antegrade Subadventitial Tracking
• Looped wire has no directional control for
•
•
•
•
branches
Crossing sidebranches with dissection plane can
lead to large sidebranch and perforating branch
loss
Distal reentry unpredictable at best
Contrast enhanced STAR may be improvement,
but does not control these variables
Predicated on SFA CTO intervention, but not the
way this intervention is commonly practiced
Antegrade Dissection
redirection versus re-entry
Lumen
CTO
Distal cap
STAR
CTO
Distal cap
Lumen
LAST
CTO
Distal cap
LAST
Lumen
Limited Antegrade Subintimal Tracking
the LAST technique
Unsuccessful
parallel wire at CTO
Knuckle wire for limited
distance to change wiring
location
Attack him where he is unprepared, appear where you are not expected
Sun Tzu (722–481 BC)
Limited Subadventitial Tracking and
Reentry (LAST)
Thompson CA, Lombardi WL, unpublished data
Limited Subadventitial Tracking and
Reentry (LAST)
Thompson CA, Lombardi WL, unpublished data
Limited Subadventitial Tracking and
Reentry (LAST)
Sidebranch recovery and distal to proximal rebuild
Thompson CA, Lombardi WL, unpublished data
Limited Subadventitial Tracking
and Reentry (LAST)
Thompson CA Lombardi WL, unpublished data
Limited Subadventitial Tracking and Reentry (LAST)
technique
• Supportive 8Fr guide
• Create or use existing dissection in proximal CTO
(Miracle, Confianza, etc.)
• Support catheter or 1.5mm balloon into track
• Pilot 50 or Pilot 200 with tight “J” tip/”umbrella
tip” or with standard bend
• Advance with balloon support, avoid spinning
wire if possible

Maintain small subadventitial space
• Exchange for CTO wire
• Reentry



Intralesional redirection
Bifurcation reentry
Small Vessel reentry
Potential Workflow Algorithm
Unsuccessful
antegrade/parallel wire,
no retrograde options
STAR
LAST
IVUS guided wiring
Limited Subadventitial Tracking and
Reentry (LAST)
Conclusions
• Relatively safe and effective alternative method to
cross coronary CTO
 conventional antegrade failure
 poor retrograde option
 Move the battlefield from a place you cannot
win to a place where you can
• Learning curve
• IVUS guided and STAR can still be performed
with unsuccessful LAST
• Dedicated reentry technologies may improve this
technique