Aim: There are limited data on safety of the STAR-

technique for treatment of chronic total occlusions

(CTO) and some concerns arise for major risk of stent
thrombosis (ST). Aim of the study was to evaluate the
mid-term clinical outcomes after successful
recanalization with STAR compared to conventional-
anterograde CTO recanalization (CA-CTO).
Methods and Results: Between June 2005 and June
2007, a total of 356 patients with successful
angiographic recanalization of at least one CTO
lesion were consecutively registered, including 75
(21.1%) who underwent STAR and 281 (78.9%) who
underwent CA-CTO recanalization. All patients were
followed for more than 1.5 years (median 2 years) for
occurrence of cardiac events. Mid-term survival rates
were estimated with Kaplan-Meier method.
Compared to CA-CTO pts, the following clinical and
angiographic characteristics were significantly more
frequent in STAR patients: hypercholesterolemia
(84% vs. 67%, p=0.004), previous CABG (41.3% vs.
15.7%,p<0.0001), 3-vessels disease, (62.7% vs. 47%,
p=0.019), RCA-CTO (62.7% vs. 41.6, p=0.002). No
significant differences were found in the use of DES
(89.2% vs. 93.5%). Average follow-up periods were
796352 and 775374 days for STAR and CA-CTO
patients, respectively. At 1.5 years there was no
significant difference in terms of cardiac survival
rates (97.3% vs. 97.8% STAR and CA-CTO,
respectively, Log-rank p=0.778) and of probable and
definite ST rates (0% vs. 1.1% STAR and CA-CTO,
respectively, p=0.803). Target-lesion-
revascularization (TLR) free survival rate in the
STAR group was significantly higher than CA-CTO
(70.6% vs. 86.8%, p=0.005).
Conclusions: At mid-term follow-up the STAR
technique was not inferior to CA-CTO in terms of
cardiac death and ST rates. Previous data of more
incidence of TLR with STAR were confirmed.
Table 1 Baseline clinical and lesions characteristics
Guided-STAR
pts (n=75)
CA-CTO
pts (n=281)
p value
Age, yrs 61.229.1 62.269.3 .392
Male gender 69 (93.2) 239 (85.1) .064
Current smoker 9 (12.2) 44 (15.7) .453
Hypercholesterolemia 62 (84) 189 (67) .005
Hypertension 59 (79.7) 201 (71.5) .156
Diabetes mellitus 24 (32.4) 81 (28.8) .545
IDDM 5 (6.8) 26 (9.3) .499
Prior myocardial infarction 39 (52.7) 141 (50.2) .699
Prior PCI 42 (56.8) 135 (48) .182
Prior CABG 31 (41.3) 44 (15.7) .000
Chronic kidney disease
*
2 (2.7%) 14(5) .400
Left ventricular ejection
fraction, %
53.168.5 52.210 .451
Three-vessel disease 47 (62.7) 132 (47) .011
Target Vessel
LAD 4 (5.4) 98 (34.9) .000
LCX-OM 23 (31.3) 66 (23.5) .180
RCA 47 (63.5) 117 (41.6) .001
In-stent restenosis 3 (4.1) 40 (14.2) .017
Prior CTO attempt 21 (28.4) 43 (15.3) .009
Stents
Mean stent length, mm (mean
SD)
68.1533.6 54.0529.4 .000
Only BMS, N (%) 7 (9.6%) 18 (6.5) .366
Only DES, N (%) 66 (89.2) 258 (93.5) .366
Complete revascularization 34 (45.9) 150 (53.4) .255
Duration of DAT, days
DAT <6 months 4 (5.4) 20 (7.1) .597
DAT 6 months 6 (8.2) 16 (5.7) .448
DAT > 6 months 64 (86.4) 245 (87.2) .583
DAT days, mean 449.263 43756 .803
Table 2 Major Adverse Cardiac Events at long term follow-up
Guided-STAR pts CA-CTO pts p value
*Clinical follow-up, N
(%)
73 (97.3%) 258 (91.8%) -
Days follow-up,
meanSD (median)
796352 (779) 775374 (801) .913
Death 3 (4.1%) 9 (3.5%) .802
Cardiac death 2 (2.7%) 7 (2.7%) .990
Acute MI 2 (2.7%) 8 (3.1%) .874
CABG 2 (2.7%) 1 (0.4%) .061
TVR 35 (47.9%) 54 (20.9%) .000
TLR 22 (30.1%) 41 (15.9%) .006
TLR clinically-driven 13 (17.8%) 21 (8.1%) .016
MACE 39 (53.4%) 62 (24%) .000
Stent thrombosis 2 (2.7%) 4 (1.4%) .448
Definite 0 3 (1.2%) .355
Probable 0 0 -
Angiographic follow-up,
N (%)
63 (85.1%) 201 (78%) -
Time to angiographic
follow-up in days,
meanSD (median)
310120 (196) 29888 (189) .778
Restenosis 34 (54%) 61 (30%) .000
TLR success 25/27 (92.6%) 50/55 (91%) .738
Clinical outcome of the Subintimal-Tracking and Re-entry (STAR) technique compared to
anterograde CTO recanalization
Cosmo Godino, Alfonso Ielasi, Raffaele Lacquaniti, Azeem Latib, Rasha Al-Lamee, Marco Mussardo, Giorgio Bassanelli, Alaide Chieffo, Mauro Carlino, Antonio
Colombo. San Raffaele Hospital, IRCCS, Milan, Italy