Long-Term Outcomes of Successful CTO PCI Using Antegrade and Retrograde Dissection and Re-entry Technique: The LOTUS study

Background: There are always concerns regarding the durability of subintimal stenting after contemporary chronic total occlusion (CTO) recanalization. Method: This prospective, multicenter clinical trial aimed to compare extraplaque (EP) and intraplaque (IP) tracking for long-term clinical outcomes after CTO recanalization. After IVUS assessment of the wire crossing position, the patients were divided into two groups: (1) the EP group with subintimal length (SL) > 10 mm; and (2) the IP group with intraplaque or minor extraplaque (SL ≤ 10 mm). The primary endpoint was binary in-segment restenosis (ISR), and the secondary endpoint was the occurrence of major adverse cardiac events. Angiographic follow-up (FU) was scheduled at 13 months, and clinical FU was continued up to 3 years. Results: A total of 257 successful CTO patients were enrolled. The mean CTO length in the EP group was 46.6 ± 16.1 mm, and the median extraplaque length was approximately 24.5 mm. The J-CTO score was higher (p<0.001). Angiographic FU at 13 months showed that both groups had similar cumulative rates of ISR (p = 0.704). In the 3-year clinical follow-up, the cumulative incidence of target vessel revascularization (TVR) in both groups and across different tracking techniques showed no significant difference (p > 0.05). Independent predictors of ISR were a total stent length >50 mm and a wire crossing time >2 hours, while multivessel lesions showed an independent association with 3-year TVR. Conclusion: The specific long extraplaque tracking had comparable angiographic and long-term clinical outcomes to intraplaque tracking, regardless of the crossing technique used.