Mid-term outcomes of chronic total occlusion percutaneous coronary intervention with subadventitial vs. intraplaque crossing: A systematic review and meta-analysis

Background Some reports have demonstrated increased risk with subadventitial chronic total occlusion (CTO) crossing, whereas others suggest equipoise between subadventitial and intraplaque crossing techniques. We sought to clarify the effect of subadventitial lesion crossing on mid-term outcomes of CTO percutaneous coronary intervention (PCI). Methods We conducted a systematic review and meta-analysis of studies reporting post-discharge outcomes after CTO PCI performed via subadventitial vs. intraplaque approaches. Results Five studies comprising a total of 2,539 patients were included. Compared with intraplaque crossing (n = 1,654, 65.1%), subadventitial cases (n = 885, 34.9%) had a higher J-CTO score (2.9 ± 1.2 vs. 1.6 ± 1.2, p < 0.001), and required significantly longer stent lengths (difference in means: 19.66 mm [95% confidence interval (CI), 11.23 to 28.08]; p < 0.001). At a median follow-up of 12.0 months, subadventitial CTO crossing was associated with a higher overall rate of target vessel revascularization (TVR, crude rate, 11.5% vs. 7.6%, odds ratio [OR]: 2.19 [95% CI, 1.62 to 2.95]; p < 0.001); the risk was higher in studies of extensive compared with limited dissection and re-entry techniques (OR: 3.46 [95% CI: 2.24 to 5.36] vs. 1.52 [95% CI, 0.94 to 2.46], p_interaction = 0.013). The rates of stent thrombosis, myocardial infarction, and cardiovascular mortality did not vary significantly between subadventitial and intraplaque crossing. Conclusions CTOs treated with subadventitial crossing were significantly more complex as compared with CTOs treated with intraplaque crossing. Extensive subadventitial crossing techniques were associated with higher TVR rates as compared with limited techniques, supporting the important role of limited techniques in the treatment of complex CTOs.