Long-term Outcomes of Successful Chronic Total Occlusion Percutaneous Coronary Interventions Using the Antegrade and Retrograde Dissection and Re-entry Approach
Phase: NA
Conditions: Chronic Total Occlusion of Coronary Artery
Sponsor: Xijing Hospital

 
Long-term outcomes of successful chronic total occlusion 
percutaneous coronary interventions using the antegrade and 
retrograde dissection and re-entry approach.  
（LOTUS-ADR/RDR） 
 
Protocol 
 
Sponsored by:  Department of  Cardiology,  Xi’jing Hospital.  
The Fourth Militrary Medical University (FMMU) 
Approved by:  Ethics Committee, Xi’jing Hospital.  FMMU 
Approved Ethical Number: KY20172019-1 
Approved date: 2017.03.15 
Last Update: 2018.11.20 
Study Time：2018.12.01- 2019.12.30 
Versions：V2.0 
 
 
 
 
 
 

ABSTRACT 
BACKGROUND：Chronic total occlusion (CTO) angioplasty is one of the most 
challenging procedures remaining for the interventional operator. Today, with 
contemporary CTO negotiation available strategies and significant operator expertise, 
the literature reports a 50-95% success rate for recanalizing CTOs. But PCIs of CTO 
lesions still carry a high rate of in-stent restenosis (ISR). Because previous reports 
have not specifically compare contemporary antegrade and retrograde dissection and 
re-entry dissection (ADR/RDR) technique on the long-term impact of ISR, so the 
investigators focused on the objective.  
OBJECTIVES: This study hope to evaluate the frequency of angiographic ISR and 
further elucidate some ISR related higher risk factors among CTO PCI patients in 
intimal stent group using antegrade or retrograde wire escalation (AWE/RWE) 
techniques and sub-intimal stent group using contemporary antegrade or retrograde 
dissection and re-entry (ADR and/or RDR). 
METHODS: A total of 300 consecutive selected patients with CTO lesion who will 
undergo successful revascularization by AWE/RWE and ADR/RDR techniques 
treatment will be enrolled in this prospective multicenter registry from December 1 
2018 to December 31 2019. The primary study endpoint of the protocol is the bionary 
in-stent restenosis of CTO vessels at angiographic follow-up about 13 months.  The 
secondary endpoints are: 1) CTO technique and procedure success rate; and 2) 
in-hospital and 30 days MACE (Cardiac death, acute myocardial infarction, urgent 
repeat tratget vessel revascularization with either pericardiocentssis or surgery and 
stroke and stent thrombosis and stroke); 6months and 1-year and 2-year MACE 
including death, MI, and target CTO vessel revascularization and stroke ; and 3) 
Restenosis  scores (R-scores) of related risk factors. 
 
CONCLUSIONS：This study expect to identify long-term effect of ADR and RDR 
methods on the ISR incidence and predictors. 
 

INTRODUCTION 
Chronic total occlusion (CTO) angioplasty is encountered in 18.4% to 52% of 
patients with coronary artery disease (CAD) undergoing coronary angiography1–4. 
Observational studies suggest that successful CTO PCI can provide significant 
clinical benefit to patients, including symptom relief, improved left ventricular 
function, reduced risk of arrhythmias, and better tolerance of an acute coronary 
syndrome5. CTO is considered one of the most difficult lesion types to treat. With the 
development of new techniques and dedicated devices, procedural success rates for 
CTO recanalization have vary between 60% and 90% in recent years 6-10.  
However, CTO lesions have a 1.4- to 5-fold higher rate high risk of in-stent 
restenosis (ISR), compared with non-occlusive stenosis11–16. ISR, induced by 
neointimal hyperplasia, is a long-recognized, chronic complication following PCI. 
Previous studies have reported clinical or lesion-related characteristics (i.e., complex 
lesion morphology or comorbidities, such as diabetes mellitus) 17, 18 and calcification 
and CTO length are known as ISR predictors 19. Whereas Valenti et al. reported that 
specific techniques (the subintimal tracking and re-entry technique (STAR) was 
associated with ISR 11.  
The STAR technique was the first reported antegradesubintimal dissection and 
reentrymethod to re-open occluded arteries20,21. Although this technique has some 
limitations, notably the inability to control the reentry point in the distal lumen, it did 
effectively demonstrate that blunt dissection through the subintimal space could 
rapidly and safely traverse even very long, tortuous, and calcified occluded segments 
without vessel perforation20-24. This demonstration provided the confidence to further 
explore the use of the subintimal space for therapeutic purposes23. STAR was 
integrated into a retrograde approach (e.g. Controlled Antegrade and Retrograde 
subintimal Tracking (CART)) 25-27, and a dedicated antegradedissection and re-entry 
system (CrossBossTM Catheter and StingrayTM System) 28. As a result of these 
advances and greater operator experience, success rates of CTO PCI have increased29.  
There have been concerns raised that the high restenosis rate after STAR30-33 may 

be a direct consequence of subintimal stenting. If the cause of the high incidence of 
restenosis is, in fact, due to use of the subintimal space, newer CTO techniques, which 
are based on controlled subintimal dissection and reentry methods, also would be 
expected to be associated with this adverse outcome 25–28 Now there are only limited 
data about procedural success of ADR and RDR and retrograde technical have been 
demonstrated and the use of subintimal stenting did not adversely impact outcomes 34, 
35. While prospective studies with longer follow-up are needed to assess the long-term 
safety and efficacy of sub-intimal stenting.  
The purpose of the study was therefore to examine the longer-term outcomes of 
patient who underwent successful CTO PCI in our program, compare the effect of 
ADR/RDR on outcomes with everolimus-eluting stents (EES) and assess predictors of 
long-term events. 
METHODS 
1. Trial overview and study population. 
① This clinical trial is a prospective, exploratory, nonrandomized, multicenter trial 
evaluating the frequency of angiographic restenosis and clinical outcomes among 
patients undergoing CTO PCI in intimal stent group using antegrade or retrograde 
wire escalation (AWE/RWE) techniques and sub-intimal stent group using 
contemporary antegrade or retrograde dissection and re-entry (ADR or RDR) with 
everolimus-eluting stents (XIENCE Coronary Stent).  
②According to high patient’s volume registry studies in CTO lesions, the patients 
percentage of ADR or RDR strategy application was just only 20-25%36-37. If to get 
60 patients for ADR or RDR strategies, the minimum CTO number are 300 patients. 
So in our registry study, 300 CTO cases, to which PCI will be attempted, are 
prospectively enrolled from December1 2018 to December 31 2019 in the CTO 
registries of ten centers. The study was approved by the institutional review board at 
each site. For patients with multiple treated CTO, only the first CTO attempted was 
considered for the analysis.  
③ Exclusions included age <18-years-old or >85-years-old, left ventricular ejection 

fraction ≦30%, allergy to medications (antiplatelet drugs, heparin, metal alloys, or 
contrast agents), a planned surgery within 6 months of PCI or planned thrombolysis, 
pregnant, a life expectancy of <6 months. 
④ Patients will sign written informed consent for long-term telephone FU before the 
interventional procedure. The patients will be followed by a clinical visit or by a 
telephone interview for 30 day, 6 months and 12 months and 24 months 
post-procedure for assessment of adverse events. All patients with successful CTO 
PCI and without moderate or severe renal insufficiency will be scheduled for 
angiographic follow-up at 13 months. Compared with CTA, coronary angiography to 
evaluate restenosis is appropriate in all patients especially for severe coronary heart 
diseases patients with atrial fibrillation and ventricular arrhythmia. It could provide 
accurate information about mild-severe angulation lesion andthe stentstraits like total 
stent length.Procedural and outcome data collection will be collected and entered by 
operators entered into a dedicated database.  
⑤ The study will be performed in accordance with the Declaration of FMMU. 
2. Study endpoints and definitions   
① The primary study endpoint of the protocol is the bionary in-stent restenosisof 
CTO vessels at the scheduled angiographic follow-up at 13 months. The secondary 
endpoints are: 1) CTO technique and procedure success rate; and 2) in-hospital and 30 
days MACE (Cardiac death, acute myocardial infarction, urgent repeat tratget vessel 
revascularization with either pericardiocentssis or surgery and stroke and stent 
thrombosis and stroke); 6 months and 1-year and 2-year MACE including death, MI, 
and target CTO vessel revascularization and stroke ; and 3) Restenosis  scores 
(R-scores) of related risk factors.② Coronary CTOs will be defined as angiographic 
evidence of total occlusions with TIMI (Thrombolysis In Myocardial Infarction) flow 
grade 0 and estimated durations of at least 3 months. Estimation of the occlusion 
duration is based on first onset of anginal symptoms, prior history of myocardial 
infarction in the target vessel territory, or comparison with a prior angiogram. 
③ Procedural success will be defined as angiographic success(final residual stenosis 
<30% by visual estimation and TIMI flow grade 3 after CTO recanalization).  

④ Clinical success will be defined as a procedural success without In-hospital 
MACCEs. In-hospital MACCEs is defined as the composite of non-Q-wave and 
Q-wave myocardial infarction (MI), recurrent angina requiring urgent repeat 
revascularization with PCI orcoronary bypass surgery, stroke, and death. Non-Q-wave 
MI is defined as creatine kinase-MB enzyme elevation >3 times the upper limit of 
normal. When new pathological Q waves, in addition to enzyme elevation, will be 
observed on the electrocardiogram, the event is defined as a Q-wave MI. In all 
patients, creatine kinase and creatine kinase-MB is evaluated 6 h after the procedure 
and until theirnormalization iflevels is abnormal.  
⑤ Lesion complexity will be judged using the J-CTO (Multicenter CTO Registry in 
Japan)score(0 ¼ easy,1 ¼ intermediate, 2 ¼ difficult, $3 ¼ very difficult)(20)and 
calculated by allocating 1 point each for:non-tapered proximal cap (ie, blunt or 
ambiguous), any calcification, any tortuosity, occlusion length >20 mm and any prior 
unsuccessfulattempt. J-CTO score of ≥2 was defined as complex. 
⑥ CTO proximal cap location is defined according to American Heart Association 
(AHA) classification and additionally coded as either ostial or non-ostial and 
proximal (left main, proximal left anterior descending, proximal circumflex or 
proximal right coronary artery) or distal (all other sites). Cap morphology is coded as 
blunt or tapered, or as ambiguous when there is lack of clarity over the origin of the 
ongoing vessel. Calcification within the CTO is coded as none visible, mild(spots 
only), moderate (<50% of vessel circumference) or severe (>50% of vessel 
circumference). Tortuosity is assessed at baseline or after subsequent equipment 
passage and coded as straight (no bend or <45° single bend), slight (>45° single bend), 
moderate (2 bends >45° or 1 bend >90°) or severe (2bends >90° or 1 bend >120°). 
Disease proximal and distal to the CTO is classified as absent, mild, moderate or 
severe. Aproximal or distal cap side branch is considered present if occurring ≤3 mm 
from the respective CTO cap. Occlusion length is estimated by dual injection, or from 
apparent length after guidewire crossing. Collaterals are classified according to Cohen 
and Rentrop and deemed interventional if, on angiographic inspection, are thought 
amenable to crossing by a guidewire and a microcatheter by the operator. 

⑦ All deaths are considered cardiac unless otherwise documented. Stent thrombosis 
is defined according to the Academic Research Consortium criteria (13). 
Reocclusionis defined as a TIMI flow grade of 0 to1in the target CTO vessel, where 
restenosis is defined as > 50% luminal narrowing at the segment site, including the 
stent and 5 mm proximal and distal to the stent edges. Target lesion revascularization 
(TLR) is defined as any repeat PCI or coronary artery bypass graft surgery of the 
target lesion that includes 5 mm proximal and distal to the stented vessel segment. 
⑧ A procedure is considered retrograde if an attempt is made to cross the lesion 
through a collateral vessel supplying the target vessel distal to the lesion. Complex 
lesions with unclear location of the proximal cap or with poor distal target are initially 
attempted by the retrograde approach. In those cases, after positioning of a 
microcatheter at the distal CTO cap, a true-to-true retrograde lumen crossing 
technique is first attempted for shorter lesions (<20 mm). When entering in the 
subintimal space or with longer lesions, knuckled wires are used to reach the proximal 
cap, followed most often by reverse-controlled anterograde and retrograde re-entry 
techniques. 
⑨ A procedure is considered antegrade if no retrograde crossing attempts are made. 
An anterograde approach is initially attempted for short lesions (<20 mm) with clear 
proximal cap location and good distal vessel target using a wiring strategy. 
Anterograde dissection/re-entry using dedicated devices (CrossBoss and Stingray 
catheters) is, however, preferred for longer lesions with an optimal distal re-entry 
zone, without significant side branches that could be occluded by the technique, or 
when 
an 
initial 
wire 
escalationstrategy 
failed. 
Wire-based 
anterograde 
dissection/re-entry was also used successfully when an initial attempt at crossing from 
a “true-to-true” approach failed. Such a strategy involves the use of a microcatheter 
delivered on a knuckled polymer-jacketed wire advanced into the subintimal 
dissection plane, with subsequent re-entry into the true distal lumen using a stiff 
tapered guidewire or a knuckled guidewire. A Stingray system will be used to cross 
from the false lumen to the true lumen, the so-called hybrid procedure, rapidly 
switching from one approach to another when the initial strategy attempted is failing.  

For the main analysis, the investigators consider that the lesion is crossed with 
dissection/re-entry when (1) a wire-based anterograde dissection was performed 
followed by re-entry into the true distal lumen with a straight or knuckled 
wire/CrossBoss, (2) A Stingray system was used to cross from the false lumen to the 
true lumen, and (3) when a reverse-controlled anterograde and retrograde re-entry 
technique is used to cross the CTO segment. Other CTO crossing techniques were 
considered “intraplaque,” “true-to-true,” or wire escelation techniques(as figure 1). 
3. Intervention Procedures 
① All patients receive optimal intravenous hydration the days before and after PCI. 
② Patients receive an initial bolus of intravenous unfractioned heparin (100 IU/kg). 
The activated clotting time is monitored every 30 min to determine if an additional 
bolus of unfractioned heparin is necessary to maintain an activated clotting 
time >250s. Upstream use of glycoprotein IIb/IIIa inhibitor therapy or bivalirudinis 
avoided. 
③ All procedures are performed via the radial or/and femoral route, with double 
coronary cannulation and contralateral selective injection. Seven-French guiding 
catheters are used in most cases.  
④ All operators have received proctoring in AWE, antegrade dissection re-entry 
(ADR), retrograde wire escalation (RWE) and retrograde dissection re-entry (RDR) 
approaches used in the hybrid algorithm. And operators have performed a career 
minimum of 300 CTO cases. 
⑤To adjust the patients number in intimal stents group and subintimal stents group 
with either the antegrade or the retrograde approach,wire escalation technique was 
made as the first choice in all patients, if failed, to choose which CTO 
revascularization strategy is left to the operator’s discretion (Fig 1).The selection of 
the optimal initial CTO crossing strategy is dependent on the anatomy of the coronary 
vessels. Four angiographic characteristics are used to make the decision (Fig. 1): (a) 
lesion length (lesions ≥20 mm in length tend to have lower success rates and longer 
procedure times using standard antegrade wire escalation); (b) proximal cap location 
and morphology; (c) size, quality (i.e. vessel size and presence of luminal stenoses 

and/or calcification) and presence of side branches of the target coronary vessel at the 
distal cap; and (d) size and suitability of collateral circulation for the retrograde 
technique. Several guidewire strategies are used, including the single-wire technique, 
the parallel-wires technique, the intravascular ultrasound–guided wiring technique, 
and retrograde wiring through collateral vessels, such as simple retrograde wiring, 
kissing wires, the knuckle technique, and the CART and reverse CART techniques, as 
previously described. 
⑥ The number and type of approaches (AWE/ADR/RDR/RWE) required to cross the 
CTO segment are recorded. Wire crossing time is from insertion of the guidewire into 
either the target vessel or retrograde donor vessel to when the wire successfully 
crossed the CTO segment and re-entered the true lumen. 
⑦ The occluded segment is stented with second generation DESs(XIENCE, Abbott) 
(if no contraindication for prolonged dual antiplatelet therapy) and post-dilation 
performed to optimize stent expansion and apposition as needed.  
⑧ In this study, by evaluating CTO lesions in the pre-stenting and post-PCI period, 
the investigators seek to identify the predictors of ISR. The standard restenosis scores 
(R-scores) related six factors including: A: the number of stent (n＜2 0score; 2＞n＜4 
1score; n＞4 2score); B: stent length (＜35mm 0score; 36-70mm 1score; ＞71mm 2 
score); C: lumen dissection length (＜20mm 0score; 21-30mm 1score; ＞31mm 
2score) ; D: calcification (mild 1score; severe 2score; E: lumen area (＜5mm2 3score; 
5-7mm22score; ＞7mm2 1score) and F: angulation slight (>45° single bend 1score), 
moderate (2 bends >45° or 1 bend >90° 2 score) or severe (2bends >90° or 
1bend >120° 3score ). Additionally, the investigators will utilize IVUS as a tool to 
evaluate predictor factors to obtain in-depth analyses of the lesions. 
 

 
 Figure 1: CTO PCI techniques in trial 
4. Statistical analysis 
Discrete data are summarized as frequencies and continuous data as mean±SD or 
median and interquartile range. Chi-square test or Fisher exact test analyses were used 
for comparison of categorical variables. The multivariable analysis to evaluate the 
independent contribution of clinical, angiographic, and procedural variables to 
re-occlusion and in-segment restenosis was performed by forward stepwise logistic 
regression analysis.Cumulative survival analyses were performed using the 
Kaplan-Meier method, and the difference between curves was assessed by log-rank 
test. A multivariable analysis by forward stepwise Cox proportional hazards model 
was performed to evaluate the independent predictors of death, myocardial infarction, 
and target CTO vessel revascularization. Odds ratios (ORs), hazards ratios (HRs), and 
their 95% confidence intervals (CIs) were calculated. 
All tests were 2-tailed. A p value <0.05 was considered significant. Analyses 

were performed using the software package SPSS (version 11.5, SPSS Inc., Chicago, 
Illinois). 
REFERENCE 
1. Fefer P, Knudtson ML, Cheema AN, et al.Current perspectives on coronary chronic 
totalocclusions: the Canadian Multicenter Chronic TotalOcclusions Registry. J Am 
CollCardiol 2012;59:991–7. 
2. Christofferson RD, Lehmann KG, Martin GV,Every N, Caldwell JH, Kapadia SR. 
Effect of chronictotal coronary occlusion on treatment strategy.Am J Cardiol 
2005;95:1088–91. 
3. Werner GS, Gitt AK, Zeymer U, et al. Chronictotal coronary occlusions in patients 
with stable angina pectoris: impact on therapy and outcome inpresent day clinical 
practice. Clin Res Cardiol 2009;98:435–41. 
4. Jeroudi OM, Alomar ME, Michael TT, etal.Prevalence and management of 
coronary chronic total occlusions in a tertiary Veterans Affairshospital. Catheter 
CardiovascInterv 2014;84:637–43. 
5. Garcia S, Abdullah S, Banerjee S, BrilakisES.Chronic total occlusions: patient 
selection and overview of advanced techniques. CurrCardiol Rep2013;15:334. 
6. Joyal D, Afilalo J, Rinfret S. Effectiveness ofrecanalization of chronic total 
occlusions: asystematic review and meta-analysis. Am Heart J2010;160:179–87. 
7. Galassi AR, Tomasello SD, Crea F, et al. Transient impairment of vasomotion 
function after successful chronic total occlusion recanalization. J Am CollCardiol 
2012;59:711-8. 
8. Tomasello SD, Giudice P, Attizano T, Boukhris M, Galassi AR. The innovation of 
composite core dual coil coronary guide-wire technology: A didactic coronary chronic 
total occlusion revascularization case report, J Saudi Heart Assoc (2014),  
9. Galassi AR, Ganyukov V, Tomasello SD, Haes B, Leonid B. Successful antegrade 
revascularization by the innovation of composite core dual coil in a three-vessel total 
occlusive disease for cardiac arrest patient using extracorporeal membrane 
oxygenation. Eur Heart J 2014 Aug 7;35(30): 
10. Galassi AR, Tomasello SD, Costanzo L, Tamburino C. Antegrade techniques for 
revascularization of chronic total coronary occlusions. IntervCardiol 2010;2:377-90 
11. Valenti R, Vergara R, Migliorini A, Parodi G, Carrabba N, Cerisano G, et al. 
Predictors of reocclusion after successful drug-eluting stent-supported percutaneous 
coronary intervention of chronic total occlusion. Journal of the American College of 
Cardiology. 2013; 61(5):545–50.  
12. Park DW, Kim YH, Yun SC, Kang SJ, Lee SW, Lee CW, et al. Comparison of 
zotarolimus-eluting stents with sirolimus- and paclitaxel-eluting stents for coronary 
revascularization: the ZEST (comparison of the efficacy and safety of 
zotarolimus-eluting stent with sirolimus-eluting and paclitaxel-eluting stent for 
coronary lesions) randomized trial. Journal of the American College of Cardiology. 
2010; 56(15):1187–95.  
13. Park HJ, Kim HY, Lee JM, Choi YS, Park CS, Kim DB, et al. Randomized 

comparison of the efficacy and safety of zotarolimus-eluting stents vs. 
sirolimus-eluting stents for percutaneous coronary intervention in chronic total 
occlusion—CAtholic Total Occlusion Study (CATOS) trial. Circulation journal: 
official journal of the Japanese Circulation Society. 2012; 76(4):868–75. PMID: 
22277317. 
14. Kato M, Kimura T, Morimoto T, Nishikawa H, Uchida F, Suzuki H, et al. 
Comparison of five-year outcome of sirolimus-eluting stent implantation for chronic 
total occlusions versus for non-chronic total occlusion (from the j-Cypher registry). 
The American journal of cardiology. 2012; 110(9):1282–9.  
15. Kimura T, Morimoto T, Natsuaki M, Shiomi H, Igarashi K, Kadota K, et al. 
Comparison of everolimus-eluting and sirolimus-eluting coronary stents: 1-year 
outcomes 
from the 
Randomized 
Evaluation 
of 
Sir-olimus-eluting 
Versus 
Everolimus-eluting stent Trial (RESET). Circulation. 2012; 126(10):1225–36.  
16. Moreno R, Garcia E, Teles R, Rumoroso JR, CyrneCarvalho H, Goicolea FJ, et al. 
Randomized comparison of sirolimus-eluting and everolimus-eluting coronary stents 
in the treatment of total coronary occlusions: results from the chronic coronary 
occlusion treated by everolimus-eluting stent randomized trial. Circulation 
Cardiovascular interventions. 2013; 6(1):21–8. 
17. Takebayashi H, Mintz GS, Carlier SG, Kobayashi Y, Fujii K, Yasuda T, et al. 
Nonuniform strut distribution correlates with more neointimal hyperplasia after 
sirolimus-eluting stent implantation. Circulation. 2004; 110(22):3430–4. doi: 
10.1161/01.CIR.0000148371.53174.05 PMID: 15557367. 
18. Cassese S, Byrne RA, Tada T, Pinieck S, Joner M, Ibrahim T, et al. Incidence and 
predictors of restenosis after coronary stenting in 10 004 patients with surveillance 
angiography. Heart. 2014; 100(2):153–9.doi: 10.1136/heartjnl-2013-304933 PMID: 
24270744. 
19. Noguchi T, Miyazaki MS, Morii I, Daikoku S, Goto Y, Nonogi H. Percutaneous 
transluminal coronary angioplasty of chronic total occlusions. Determinants of 
primary success and long-term clinical out-come. Catheterization and cardiovascular 
interventions: official journal of the Society for Cardiac Angiography & Interventions. 
2000; 49(3):258–64. PMID: 10700054. 
20. Colombo A, Mikhail GW, Michev I, et al. Treating chronic total occlusions using 
subintimal 
tracking 
and 
reentry: 
The 
STAR 
technique. 
Catheter 
CardiovascInterv2005;64:407–411; discussion 412. 
21. Carlino M, Godino C, Latib A, Moses JW, Colombo A. Subintimal tracking and 
re-entry 
technique 
with 
contrast 
guidance: 
A 
safer 
approach. 
Catheter 
CardiovascInterv 2008;72:790–796. 
22. Godino C, Latib A, Economou FI, et al. Coronary chronic total occlusions: 
Mid-term comparison of clinical outcome following the use of the guided-STAR 
technique and conventional anterograde approaches. Catheter CardiovascInterv 
2012;79:20–27. 
23. Michael TT, Papayannis AC, Banerjee S, Brilakis ES. Subintimal 
dissection/reentry 
strategies 
in 
coronary 
chronic 
total 
occlusion 
interventions.CircCardiovascInterv 2012;5:729–738. 

24. Galassi AR, Tomasello SD, Costanzo L, et al. Mini-STAR as bail-out strategy for 
percutaneous 
coronary 
intervention 
of 
chronic 
total 
occlusion. 
Catheter 
CardiovascInterv 2012;79:30–40. 
25. Surmely JF, Tsuchikane E, Katoh O, et al. New concept for CTO recanalization 
using controlled antegrade and retrograde subintimal tracking: The CART technique. J 
Invasive Cardiol 2006;18:334–338. 
26. Kimura M, Katoh O, Tsuchikane E, et al. The efficacy of a bilateral approach for 
treating lesions with chronic total occlusions the CART (controlled antegrade and 
retrograde subintimal tracking) registry. JACC CardiovascInterv 2009;2:1135–1141. 
27. Rathore S, Katoh O, Tuschikane E, Oida A, Suzuki T, Takase S. A novel 
modification of the retrograde approach for the recanalization of chronic total 
occlusion of the coronary arteries intravascular ultrasound-guided reverse controlled 
antegrade and retrograde tracking. JACC CardiovascInterv 2010;3:155–164. 
28. Whitlow PL, Lombardi WL, Araya M, et al. Initial experience with a dedicated 
coronary re-entry device for revascularization of chronic total occlusions. Catheter 
CardiovascInterv 2012;80: 807–813. 
29. Whitlow PL, Burke MN, Lombardi WL, et al. Use of a novel crossing and 
re-entry system in coronary chronic total occlusions that have failed standard crossing 
techniques: Results of the FAST-CTOs (Facilitated Antegrade Steering Technique in 
Chronic Total Occlusions) trial. JACC CardiovascInterv 2012; 5:393–401. 
30. Godino C, Latib A, Economou FI, et al. Coronary chronic total occlusions: 
Mid-term comparison of clinical outcome following the use of the guided-STAR 
technique and conventional anterograde approaches. Catheter CardiovascInterv 
2012;79:20–27. 
31. Valenti R, Vergara R, Migliorini A, et al. Predictors of reocclusion after successful 
drug-eluting stent-supported percutaneous coronary intervention of chronic total 
occlusion. J Am CollCardiol 2013;61:545–550. 
32. Visconti G, Focaccio A, Donahue M, Briguori C. Elective versus deferred stenting 
following subintimal recanalization of coronary chronic total occlusions. Catheter 
CardiovascInterv 2015; 85:382–390. 
33. Carlino M, Figini F, Ruparelia N, Uretsky BF, Godino C, Latib A, Bertoldi L, 
Brilakis E, Karmpaliotis D, Antoniucci D, Margonato A, Colombo A. Predictors of 
restenosis following contemporary subintimal tracking and reentry technique: The 
importance 
of 
final 
TIMI 
flow 
grade. 
Catheter 
CardiovascInterv. 
2016 
Apr;87(5):884-92. 
34. Stojkovic S, Sianos G, Katoh O, et al. Efficiency, safety, and long-term follow-up 
of retrograde approach for CTO recanalization: Initial (Belgrade) experience with 
international proctorship. J IntervCardiol 2012;25:540–548. 
35. Rinfret S, Ribeiro HB, Nguyen CM, Nombela-Franco L, Urena M, Rodes-Cabau J. 
Dissection and re-entry techniques and longer-term outcomes following successful 
percutaneous coronary intervention of chronic total occlusion. Am J Cardiol 2014; 
114:1354–1360. 
36. Christopoulos G, Karmpaliotis D, Alaswad K, Yeh RW, Jaffer FA, Wyman RM, 
Lombardi WL, Menon RV, Grantham JA, Kandzari DE, Lembo N, Moses JW, Kirtane 

AJ, Parikh M, Green P, Finn M, Garcia S, Doing A, Patel M, Bahadorani J, Tarar MN, 
Christakopoulos GE, Thompson CA, Banerjee S, Brilakis ES. Application and 
outcomes of a hybrid approach to chronic total occlusion percutaneous coronary 
intervention in a contemporary multicenter US registry. Int J Cardiol. 2015 Nov 
1;198:222-8.  
37. Valenti R1, Vergara R, Migliorini A, Parodi G, Carrabba N, Cerisano G, Dovellini 
EV, Antoniucci D. Predictors of reocclusion after successful drug-eluting 
stent-supported percutaneous coronary intervention of chronic total occlusion. J Am 
CollCardiol. 2013 Feb 5;61(5):545-50