Journal of the American College of Cardiology Vol. 61, No.

5, 2013
© 2013 by the American College of Cardiology Foundation ISSN 0735-1097/$36.00
Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jacc.2012.10.036

Predictors of Reocclusion After Successful

Drug-Eluting Stent–Supported Percutaneous
Coronary Intervention of Chronic Total Occlusion
Renato Valenti, MD, Ruben Vergara, MD, Angela Migliorini, MD, Guido Parodi, MD,
Nazario Carrabba, MD, Giampaolo Cerisano, MD, Emilio Vincenzo Dovellini, MD,
David Antoniucci, MD
Florence, Italy

Objectives This study sought to assess the incidence of reocclusion and identification of predictors of angiographic failure
after successful chronic total occlusion (CTO) drug-eluting stent–supported percutaneous coronary intervention
(PCI).

Background Large registries have shown a survival benefit in patients with successful CTO PCI. Intuitively, sustained vessel
patency may be considered as a main variable related to long-term survival. Very few data exist about the angio-
graphic outcome after successful CTO PCI.

Methods The Florence CTO PCI registry started in 2003 and included consecutive patients treated with drug-eluting stents
for at least 1 CTO (⬎3 months). The protocol treatment included routine 6- to 9-month angiographic follow-up.
Clinical, angiographic, and procedural variables were included in the model of multivariable binary logistic re-
gression analysis for the identification of the predictors of reocclusion.

Results From 2003 to 2010, 1,035 patients underwent PCI for at least 1 CTO. Of these, 802 (77%) had a successful
PCI. The angiographic follow-up rate was 82%. Reocclusion rate was 7.5%, whereas binary restenosis (⬎50%) or
reocclusion rate was 20%. Everolimus-eluting stents were associated with a significantly lower reocclusion rate
than were other drug-eluting stents (3.0% vs. 10.1%; p ⫽ 0.001). A successful subintimal tracking and re-entry
technique was associated with a 57% of reocclusion rate. By multivariable analysis, the subintimal tracking and
re-entry technique (odds ratio [OR]: 29.5; p ⬍ 0.001) and everolimus-eluting stents (OR: 0.22; p ⫽ 0.001) were
independently related to the risk of reocclusion.

Conclusions Successful CTO-PCI supported by everolimus-eluting stents is associated with a very high patency rate. Success-
ful subintimal tracking and re-entry technique is associated with a very low patency rate regardless of the type
of stent used. (J Am Coll Cardiol 2013;61:545–50) © 2013 by the American College of Cardiology Foundation

Large registries have shown a survival benefit in patients (4 –12). The aim of this study was to assess the incidence of
with successful chronic total occlusion (CTO) percutaneous reocclusion and identification of predictors of angiographic
coronary intervention (PCI) as compared to unsuccessful or failure after successful drug-eluting stent (DES)–supported
unattempted CTO PCI (1– 4). Intuitively, sustained vessel CTO PCI.
patency may be considered as a main variable related to
long-term survival. Very few data exist about the angio- See page 551
graphic outcome of successful CTO PCI, because random-
ized studies comparing different types of stents had small Methods
sample sizes; most registries did not include angiographic
follow-up; and sparse data are available from a few small Patients and treatment. The Florence CTO PCI registry,
registries with a very low angiographic follow-up rate started in 2003, includes consecutive patients treated with
DES for at least 1 CTO. Details on this registry have been
previously published (4,10). CTO was defined as a coronary
From the Division of Cardiology, Careggi Hospital, Florence, Italy. The authors have obstruction with TIMI (Thrombolysis in Myocardial In-
reported that they have no relationships relevant to the contents of this paper to farction) flow grade 0 with an estimated duration ⬎3
disclose.
Manuscript received July 3, 2012; revised manuscript received September 28, 2012, months. The duration of the occlusion was determined by
accepted October 23, 2012. the interval from the last episode of acute coronary syn-
546 Valenti et al. JACC Vol. 61, No. 5, 2013
CTO Reocclusion February 5, 2013:545–50

Abbreviations drome, or in patients without a addition to creatine kinase-myocardial band elevation. Cre-
and Acronyms history of acute coronary syn- atine kinase-myocardial band fraction was routinely assessed
dromes, from the first episode of 12 h after PCI in all patients or at least 3 times every 6 h in
CI ⴝ confidence interval(s)
effort angina consistent with the patients with recurrent chest pain.
CTO ⴝ chronic total
occlusion
location of the occlusion or by a All patients had scheduled clinical and electrocardio-
previous coronary angiography. graphic examinations at 6 months and at 1 and 2 years. All
DES ⴝ drug-eluting stent(s)
In patients without a history of other possible information derived from hospital readmis-
EES ⴝ everolimus-eluting
stent(s)
angina and who were admitted sion or by the referring physician, relatives, or municipality
for an acute coronary syndrome live registries were entered into the prospective database.
HR ⴝ hazard ratio(s)
or ST-segment elevation acute All patients with successful CTO PCI and without
OR ⴝ odds ratio(s)
myocardial infarction with a def- moderate or severe renal insufficiency were scheduled for
PCI ⴝ percutaneous inite identification of the culprit angiographic follow-up at 6 to 9 months. Unscheduled
coronary intervention
vessel, associated total occlusion angiography was allowed based on clinical indication. An-
STAR ⴝ subintimal
of a nonculprit vessel was consid- giographic parameters were assessed using a computer
tracking and re-entry
ered as a chronic occlusion if analysis system (Innova 2100IQ, General Electric Health-
TIMI ⴝ Thrombolysis In
Myocardial Infarction
there was angiographic evidence care Technologies, Little Chalfont, Buckinghamshire,
of filling the vessel through col- United Kingdom).
laterals. The indication for the Endpoints. The primary endpoint of the study was reoc-
percutaneous treatment of CTO was the demonstration of clusion of the CTO vessel at the scheduled or unscheduled
viable myocardium in the territory of the occluded vessel by angiographic follow-up. The secondary endpoints were:
echographic or scintigraphic provocative tests, whereas no 1) binary angiographic restenosis; 2) 1-year major adverse
CTO angiographic characteristic was considered as an cardiac events including death, myocardial infarction, and
absolute contraindication to PCI attempt. Thus, patients target CTO vessel revascularization; and 3) definite CTO
with long occlusions, extensive calcification, bridging col- stent thrombosis. Reocclusion was defined as a TIMI flow
laterals, a nontapered stump, or a side branch at the grade 0 to 1 in the target vessel, whereas restenosis was
occlusion site were included. Occlusion length was assessed defined as ⬎50% luminal narrowing at the segment site
from the beginning of the occlusion to the distal antegrade including the stent and 5 mm proximal and distal to the
or retrograde vessel by filling from bridge collaterals or stent edges. For patients with multiple treated CTO, only
collaterals provided by a coronary artery other than the the first CTO attempted was considered for the analysis. All
CTO vessel and using simultaneous contrast medium in- deaths were considered cardiac unless otherwise docu-
jection in both right and left coronary arteries. All occlu- mented. Stent thrombosis was defined according to the
sions were attempted using the anterograde or retrograde Academic Research Consortium criteria (13).
approach and dedicated coronary wires (hydrophilic and Statistical analysis. Discrete data are summarized as fre-
nonhydrophilic) and devices. The anterograde approach was quencies and continuous data as mean ⫾ SD or median and
the first option treatment in all but right coronary ostium interquartile range. Chi-square test or Fisher exact test
CTO. Subintimal tracking and re-entry (STAR) technique analyses were used for comparison of categorical variables.
was used only after failed anterograde and retrograde ap- The multivariable analysis to evaluate the independent
proaches. Three types of DES were used during the study contribution of clinical, angiographic, and procedural vari-
period: first-generation sirolimus-eluting stent (Cypher, ables to reocclusion and in-segment restenosis was per-
Cordis Corp., Miami Lakes, Florida), first-generation formed by forward stepwise logistic regression analysis. The
paclitaxel-eluting stent (Taxus Express or Taxus Liberté, following variables were tested: diabetes mellitus; renal
Boston Scientific, Natick, Massachusetts), and everolimus- insufficiency; CTO stent length ⬎40 mm; STAR tech-
eluting stent (EES) (either Xience V, Abbott Vascular, nique; EES; year of the index procedure. Cumulative
Santa Clara, California; or Promus, Boston Scientific). survival analyses were performed using the Kaplan-Meier
Standard stent implantation techniques, including mini- method, and the difference between curves was assessed by
mum overlap between stents and routine post-dilation using log-rank test. A multivariable analysis by forward stepwise
final high balloon pressure (ⱖ16 atm) were used. All Cox proportional hazards model was performed to evaluate
patients were pre-treated with aspirin (300 mg/day) and the independent predictors of death, myocardial infarction,
clopidogrel (loading dose 600 mg). Aspirin (300 mg/day) and target CTO vessel revascularization. The following
was continued indefinitely and clopidogrel (75 mg/day) for variables were tested: age ⬎75 years; diabetes mellitus;
at least 12 months. previous myocardial infarction; renal insufficiency; acute
Procedural success was defined as a final diameter stenosis coronary syndrome at admission; left ventricular ejection
⬍30% with a TIMI flow grade 3 of the CTO vessel without fraction ⬍0.40; 3-vessel disease; CTO vessel; CTO stent
death, or Q-wave myocardial infarction, or emergency length ⬎40 mm; STAR technique; EES; completeness of
coronary surgery. A Q-wave myocardial infarction was revascularization; year of the index procedure. Interaction
defined as new Q waves in 2 or more contiguous leads in between EES and year of the index procedure was tested
JACC Vol. 61, No. 5, 2013 Valenti et al. 547
February 5, 2013:545–50 CTO Reocclusion

with multivariable regression models. Odds ratios (ORs), Baseline

Table 1 Clinical and Clinical
Baseline Angiographic Characteristics
and Angiographic Characteristics
hazards ratios (HRs), and their 95% confidence intervals
(CIs) were calculated. Successful CTO PCI
A propensity score-matched analysis (1:1) was also per- (n ⴝ 802)
Age, yrs 68 ⫾ 11
formed to reduce bias due to a different time frame in the
⬎75 233 (29)
use of first-generation (paclitaxel- and sirolimus-eluting)
Male 680 (85)
and second-generation (everolimus-eluting) DES. An op-
Hypertension 485 (60)
timal data-matching technique was performed using pro- Hypercholesterolemia 458 (57)
pensity score as caliper. Propensity score analysis was Current smokers 158 (20)
performed with the use of a logistic regression model from Diabetes mellitus 200 (25)
which the probability for the use of EES was calculated for Previous myocardial infarction 405 (50)
each patient. The variables entered into the model were: age Previous PCI 289 (36)
⬎75 years; male; diabetes mellitus; left ventricular ejection Previous coronary surgery 91 (11)

fraction ⬍0.40; 3-vessel disease; CTO vessel; CTO length Renal insufficiency, creatinine ⬎250 ␮mol/l 18 (2.2)

⬎20 mm; CTO vessel reference diameter ⬍2.5 mm; CTO ACS 255 (32)
44 ⫾ 12
heavy calcification; CTO stent length ⬎40 mm; adjunctive LVEF
⬍40% 298 (37)
rotational atherectomy; STAR technique; completeness of
Multivessel disease 660 (82)
revascularization. Model discrimination was assessed with 3-vessel disease 393 (49)
the C-statistic and goodness of fit with the Hosmer- CTO vessel
Lemeshow test. LAD 248 (31)
All tests were 2-tailed. A p value ⬍0.05 was considered LCX 177 (22)
significant. Analyses were performed using the software RCA 329 (41)
package SPSS (version 11.5, SPSS Inc., Chicago, Illinois). Others 48 (6)

Values are mean ⫾ SD or n (%).

ACS ⫽ acute coronary syndrome(s) (includes unstable angina and non–ST-segment elevation
Results myocardial infarction); CTO ⫽ chronic total occlusion; LAD ⫽ left anterior descending artery; LCX ⫽
left circumflex; LVEF ⫽ left ventricular ejection fraction; PCI ⫽ percutaneous coronary intervention;
From 2003 to 2011, 1,035 patients underwent a PCI RCA ⫽ right coronary artery.
attempt for at least 1 CTO. Of these, 802 (77%) had a
successful PCI. was 10.1% in patients treated with first-generation DES,
Table 1 summarizes the baseline patient characteristics. and 3% in patients treated with EES (p ⫽ 0.001). The
The mean age was 68 ⫾ 11 years; 25% of patients had reocclusion rate was 57% in patients treated using the
diabetes mellitus; and one-half of patients had a history of STAR technique and 5.1% using non-STAR techniques
myocardial infarction. The majority of patients had multi- (p ⬍ 0.001). Of 25 patients treated successfully using the
vessel disease, and 3-vessel disease was revealed in 49%. retrograde approach, angiographic follow-up was available for
One-hundred and twenty-two patients were treated for 2 or 19, and no reocclusion was revealed. Nonocclusive restenosis
3 CTO. was revealed in 79 patients (nonocclusive restenosis rate
Table 2 summarizes the procedural characteristics. Over-
13%).
all, multivessel PCI was performed in 67% of cases, and a
There was no significant interaction between EES and
complete revascularization was achieved in 84% of patients.
year of the index procedure.
The STAR technique was used in 54 patients: recanali-
By multivariable analysis, the only variables related to
zation was achieved in 50 cases, whereas a final TIMI flow
reocclusion were the STAR technique (OR: 29.5, 95% CI:
grade of 3 was achieved in only 34 (4.2%); and EES was
used in 16 (47%). 11.9 to 73.2; p ⬍ 0.001) and EES (OR: 0.22, 95% CI: 0.09
First-generation DES were used in 66% of cases, whereas to 0.54; p ⫽ 0.001). The only variable related to the risk of
EES were used in 34%. nonocclusive restenosis was the right coronary artery CTO
Table 3 summarizes the angiographic and clinical out- (OR: 1.64, 95% CI: 1.02 to 2.62, p ⫽ 0.040).
comes. Of 802 patients, 49 were not eligible for angio- At 1-year follow-up, the cardiac mortality rate was 3.2%,
graphic follow-up because of death (n ⫽ 29: 26 cardiac the myocardial infarction rate was 0.9%, whereas 103
deaths and 3 noncardiac deaths) or moderate (n ⫽ 10) or patients (12.8%) underwent repeat PCI for restenosis or
severe (n ⫽ 10) renal insufficiency. Thus, 753 patients were reocclusion of the CTO target vessel. Major adverse cardiac
eligible for the angiographic follow-up , and 616 had events rate was significantly lower in EES than in first-
coronary angiography (follow-up rate: 82%). All eligible generation DES (11.6% vs 19%; p ⫽ 0.005). The target
patients who did not undergo angiographic follow-up were CTO revascularization rate was 14.1% in patients treated
alive and asymptomatic for angina. with first-generation DES, and 10.5% in patients treated
The target CTO vessel reocclusion was revealed in 46 with EES (p ⫽ 0.139). No patient underwent coronary
patients (reocclusion rate: 7.5%). The reocclusion rate surgery. Overall, the 3-year event-free survival rate (median:
548 Valenti et al. JACC Vol. 61, No. 5, 2013
CTO Reocclusion February 5, 2013:545–50

Procedural
Table 2 Characteristics
Procedural Characteristics Clinical
Table 3and Clinical
Angiographic Outcomes Outcomes
and Angiographic

Successful CTO PCI Successful CTO PCI

(n ⴝ 802) (n ⴝ 802)
Occlusion length, mm 1-year clinical outcome
Mean 38 ⫾ 21 MACE 131 (16)
Median 32 (22–50) Cardiac death 26 (3.2)
Length ⬎20 597 (74) Myocardial infarction 7 (0.9)
Reference CTO vessel diameter, mm CABG 0
Mean 2.63 ⫾ 0.53 CTO vessel repeat PCI 103 (12.8)
Median 2.60 (2.30–3.0) First-generation PES and SES 72/508 (14.1)
Diameter ⱕ2.5 mm 190 (24) EES 31/294 (10.5)
Adjunctive rotational atherectomy 37 (4.6) STAR 11/34 (32.3)
STAR technique 34 (4.2) Definite stent thrombosis 4 (0.4)
CTO stent implanted, n 1,509 Angiographic outcome (n ⫽ 616)
Mean stents/patient 1.88 Follow-up rate 616/753 (82)
First-generation DES (PES and SES), % 66 In-segment restenosis or 125 (20)
EES, % 34 reocclusion
CTO stent length, mm Reocclusion rate 46 (7.5)
Mean 52 ⫾ 30 First-generation PES and SES 39/385 (10.1)*
Median 44 (28–69) EES 7/231 (3.0)
CTO stent length ⬎40 432 (54) STAR 16/28 (57)
Post-PCI minimum lesion diameter, mm
Values are n (%). *p ⫽ 0.001 first-generation DES versus second-generation EES.
Mean 2.74 ⫾ 0.49 CABG ⫽ coronary artery bypass graft; EES ⫽ everolimus-eluting stent(s); MACE ⫽ major adverse
Median 2.80 (2.50–3.0) cardiac event(s); other abbreviations as in Tables 1 and 2.

Fluoroscopic time, min

Median 24 (15–36)
Discussion
Contrast, ml
The main findings of this study can be summarized as
Median 300 (200–400)
Multivessel PCI 540 (67)
follows: 1) The use of EES, as compared to first-generation
Completeness of revascularization 675 (84)

Values are mean ⫾ SD, median interquartile range, or n (%).

DES ⫽ drug-eluting stent(s); EES ⫽ everolimus-eluting stent; IQR ⫽ interquartile range; PES ⫽
paclitaxel-eluting stent(s); SES ⫽ sirolimus-eluting stent(s); STAR ⫽ subintimal tracking and
re-entry; other abbreviations as in Table 1.

21 months) was 76 ⫾ 2%. The 3-year event-free survival

rate was 55 ⫾ 14% in patients treated with the STAR
technique, and 77 ⫾ 2% in patients treated with a non-
STAR technique (p ⫽ 0.014) (Fig. 1). At multivariable
analysis by Cox analysis, the variables related to cardiac
mortality were: age ⬎75 years (HR: 4.64, 95% CI: 2.19 to
9.83; p ⬍ 0.001); left ventricular ejection fraction ⬍0.40
(HR: 7.25, 95% CI: 2.77 to 19; p ⬍ 0.001); left anterior
descending artery CTO (HR: 2.39, 95% CI: 1.13 to 4.33;
p ⫽ 0.020); complete revascularization (HR: 0.48, 95% CI:
0.24 to 0.95; p ⫽ 0.037). Variables related to major adverse
cardiac events were: age ⬎75 years (HR: 1.64, 95% CI: 1.17
to 2.31; p ⫽ 0.004); STAR technique (HR: 2.26, 95% CI:
1.21 to 4.22; p ⫽ 0.010); left ventricular ejection fraction
⬍0.40 (HR: 1.47, 95% CI: 1.06 to 2.06; p ⫽ 0.023); left
anterior descending artery CTO (HR: 1.42, 95% CI: 1.02 to
2.01; p ⫽ 0.046) (Table 4).
Definite stent thrombosis rate was 0.4%. Figure 1 Kaplan-Meier Analysis of Freedom From MACE
Table 5 summarizes the matched comparison between
patients treated with first-generation DES and EES (C- Kaplan-Meier estimates of 3-year event-free survival in patients treated with the
statistic: 0.69 and Hosmer-Lemeshow test p ⫽ 0.803 for subintimal tracking and re-entry (STAR) technique (red line) and patients
treated with a non-STAR technique (green line). MACE ⫽ major adverse cardio-
propensity score analysis). Patients treated with EES had vascular events.
better clinical and angiographic outcomes.
JACC Vol. 61, No. 5, 2013 Valenti et al. 549
February 5, 2013:545–50 CTO Reocclusion

Predictors
series that included 74 patients, the reocclusion rate was
Table 4 ofPredictors
Clinical and Angiographic
of Clinical Outcome
and Angiographic Outcome
41% (follow-up rate: 85%) (20).
Clinical Outcome HR 95% CI p Value The current study shows a very high reocclusion rate
Cardiac death (57%) after a successful CTO PCI using the STAR tech-
Age ⬎75 yrs 4.64 2.19–9.83 ⬍0.001 nique. This finding suggests limiting the use of this tech-
LVEF ⬍40% 7.25 2.77–19 ⬍0.001 nique to a very few patients: patients with failed anterograde
LAD-CTO 2.39 1.13–4.33 0.020 or retrograde attempt; patients with severe and refractory
Completeness of revascularization 0.48 0.24–0.95 0.037
symptoms; and patients with a very high surgical risk despite
MACE
a coronary anatomy suitable for bypass grafting.
Age ⬎75 yrs 1.64 1.17–2.31 0.004
STAR technique 2.26 1.21–4.22 0.010
Study limitations. This is a nonrandomized single-center
LVEF ⬍40% 1.47 1.06–2.06 0.023
study. Despite the shortcomings inherent in all registries,
LAD-CTO 1.42 1.02–2.01 0.046 the study includes the largest series of CTO PCI patients
with angiographic follow-up and provides original insights
Angiographic Outcome OR
into the clinical and angiographic outcomes after successful
Reocclusion
DES-supported PCI for CTO. The number of patients
STAR technique 29.50 11.9–73.2 ⬍0.001
treated with the STAR technique is small, preventing a
EES 0.22 0.09–0.54 0.001
Nonocclusive restenosis
definite conclusion on long-term efficacy of this technique.
RCA-CTO 1.64 1.02–2.62 0.040
However, the reported high reocclusion rate is consistent
with the rates reported in previously published small patient
CI ⫽ confidence interval(s); HR ⫽ hazard ratio(s); OR ⫽ odds ratio(s); other abbreviations as in
Tables 1 to 3.
series (8,18,19).

sirolimus- and paclitaxel-eluting stents, was associated with Conclusions

a 5-fold decrease in CTO vessel reocclusion rate. 2) The
reocclusion rate with EES was only 3%, and this finding The uses of EES and conventional anterograde or retro-
drives the difference in event-free survival between patients grade approaches to CTO are associated with very low rates
treated with first-generation DES and EES. 3) The STAR of target vessel reocclusion. Conversely, the use of the
technique allowed CTO vessel recanalization in nearly all STAR technique, even successfully, is associated with a very
cases but a final TIMI flow grade of 3 was achieved in high rate of target vessel reocclusion.
approximately 60% of patients. 4) Patients with a successful
STAR procedure (final TIMI flow grade of 3) had a very Outcome Characteristics
Baseline
Table 5
of Baseline
the Propensity
andMatched Groups
Characteristics and
Outcome of the Propensity Matched Groups
high rate of reocclusion.
The better performance of EES versus first-generation First-Generation DES EES
DES was shown in the SPIRIT (Clinical Evaluation of the (n ⴝ 294) (n ⴝ 294) p Value

XIENCE V Everolimus Eluting Coronary Stent System in Age ⬎75 yrs 77 (26) 81 (28) 0.710
Male 259 (88) 261 (89) 0.796
the Treatment of Patients With De Novo Native Coronary
Hypertension 168 (57) 185 (63) 0.152
Artery Lesions) randomized studies (14 –16) that excluded
Diabetes mellitus 64 (22) 73 (25) 0.380
CTO patients, and also in the COMPARE (Second- Previous myocardial infarction 140 (48) 168 (57) 0.021
Generation Everolimus-Eluting and Paclitaxel-Eluting LVEF ⱕ40% 108 (37) 104 (35) 0.731
Stents in Real-Life Practice) trial (17), an all-comer ran- Three-vessel disease 136 (46) 130 (44) 0.619
domized study comparing EES with first-generation LAD-CTO 107 (36) 96 (33) 0.340
paclitaxel-eluting stents. However, this study did not pro- Occlusion length ⬎20 mm 251 (85) 244 (83) 0.429
vide data on the performance of EES in CTO that Reference diameter ⱕ2.5 mm 63 (21) 63 (21) 1.00
accounted for only 3.6% of treated lesions. The increased CTO stent length ⬎40 mm 187 (64) 193 (66) 0.605

efficacy of EES in very long CTO lesions (requiring ⬎40 Rotational atherectomy 9 (3.1) 12 (4.1) 0.505

mm stent length) as compared to first-generation paclitaxel- STAR technique 12 (4.1) 16 (5.4) 0.439
Complete revascularization 249 (85) 260 (88) 0.183
eluting stents was shown in a previous nonrandomized study
1-year clinical outcome
(12). The current study confirms the increased efficacy of
MACE 66 (22.4) 34 (11.6) ⬍0.001
EES also in shorter CTO lesions. Cardiac death 14 (4.8) 3 (1.0) 0.007
There are very few data on angiographic follow-up after Myocardial infarction 8 (2.0) 1 (0.03) 0.019
PCI using the STAR technique. In the original series of CTO vessel repeat PCI 50 (17) 31 (10.5) 0.023
STAR technique applied to native coronaries described by Definite stent thrombosis 3 (1.0) 0 0.082
Colombo et al. (18), 21 patients had angiographic follow- Angiographic outcome 230 231
up, and the reocclusion rate was 24%. In a second series of In-segment restenosis or reocclusion 63 (27) 30 (13) ⬍0.001
68 patients treated with the STAR technique, the reocclu- Reocclusion 23 (10) 7 (3) 0.002

sion rate was 35% (19). However, in this study, the Values are n (%) or n.
angiographic follow-up rate was only 56%. In a more recent Abbreviations as in Tables 1 to 3.
550 Valenti et al. JACC Vol. 61, No. 5, 2013
CTO Reocclusion February 5, 2013:545–50

with sirolimus-eluting stents in total coronary occlusions: the

Reprint requests and correspondence: Dr. David Antoniucci, ACROSS/TOSCA-4 (Approaches to Chronic Occlusions With
Division of Cardiology, Careggi Hospital, Viale Morgagni Sirolimus- Eluting Stents/Total Occlusion Study of Coronary
I-50139, Florence, Italy. E-mail: david.antoniucci@virgilio.it. Arteries-4) Trial. J Am Coll Cardiol Intv 2009;2:97–106.
11. Nakamura S, Muthusamy TS, Bae JH, Cahyadi YH, Udayachalerm
W, Tresukosol D. Impact of sirolimus-eluting stent on the outcome of
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