Author + information
- Lei Song, MD,
- Akiko Maehara, MD,
- Matthew T. Finn, MD,
- Ajay J. Kirtane, MD, SM,
- Gary S. Mintz, MD and
- Dimitri Karmpaliotis, MD, PhD∗ ()
- ↵∗Columbia University Medical Center, 161 Fort Washington Avenue, Herbert Irving Pavilion, 6th Floor, New York, New York 10032
We thank Dr. Azzalini and colleagues for their interest and valuable comments. The main objective of our article was to identify the relationship between intravascular ultrasound (IVUS)-detected wiring pattern and procedural outcomes based on contemporary chronic total occlusion techniques but not the superiority or inferiority of these techniques (1).
If we included only cases with a Japan chronic total occlusion score ≥2 (n = 151; 68.9% of total cohort) to reduce the confounding effect of lesion complexity, subintimal tracking (ST) was still associated with more IVUS-detected vessel injury (hematoma, perivascular blood speckle; 94.8% vs. 60.0%; p < 0.01) and worse imaging and cardiovascular endpoint outcomes (composite of dye staining/extravasation, branch occlusion, or Society for Cardiac Angiography and Interventions [SCAI] defined periprocedural myocardial infarction [MI]: 58.3% vs. 20.0%; p < 0.01); however, there was no difference in the composite of all-cause death, SCAI-defined periprocedural MI, or target lesion revascularization (7.3% vs. 3.6%; p = 0.30).
In these complex lesions (Japan chronic total occlusion score ≥2), dissection re-entry (DR) was used in 51.0%, higher than in the total cohort (40.9%). ST was mostly observed in the DR group (90.9%), whereas intraplaque tracking was more common in the wire escalation group (64.9%). Consistent with ST, the DR technique was also associated with more IVUS-detected vessel injury (93.5% vs. 70.3%; p < 0.01) and a worse composite imaging and cardiovascular endpoint (59.7% vs. 28.4%; p < 0.01), but no difference in the composite of all-cause death, SCAI-defined periprocedural MI, or target lesion revascularization (9.1% vs. 2.7%; p = 0.10).
Azzalini et al. (2) demonstrated that the modern DR techniques had better outcomes than aggressive DR (STAR). Because nobody was treated using STAR in our study, we only compared CrossBoss/Stingray versus the retrograde DR technique (reverse CART). The reverse CART showed more IVUS-detected vessel injury (97.7% vs. 83.0%; p = 0.02), but no difference in the other imaging or clinical endpoints. As expected, longer ST length (>10 mm) was associated with more IVUS-detected vessel injury (97.1% vs. 78.3%; p < 0.01) and worse composite of all-cause death, SCAI-defined periprocedural MI, or target lesion revascularization (67.6% vs. 36.1%; p < 0.01).
Finally, based on the current study, we cannot answer such questions as what degree of vascular injury is significant enough to predict mid-term or long-term outcomes. Obviously, this requires more data and follow-up, which is in process now.
Please note: Dr. Song has received research funding from Boston Scientific. Dr. Maehara has received grant support from Boston Scientific and St. Jude Medical for fellows; is a consultant for Boston Scientific and OCT Medical Imaging Inc.; and has received speakers fees from St. JudeMedical. Dr. Finn is supported by National Institutes of Health grant 2T32HL007854-21. Dr. Kirtane has received institutional research grants to Columbia University from Boston Scientific, Medtronic, Abbott Vascular, Abiomed, St. Jude Medical, Vascular Dynamics, and Eli Lilly. Dr. Mintz is a consultant to Boston Scientific and ACIST; has received fellowship/grant support from Volcano, Boston Scientific, and InfraReDx; and has received honoraria from Boston Scientific and ACIST. Dr. Karmpaliotis is on the speakers bureaus of Abbott Vascular, Boston Scientific, and Medtronic; and is a consultant for Vascular Solutions.
- 2017 American College of Cardiology Foundation
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