Improvement of ischemia by subintimal tracking and re-entry in chronic total occlusion percutaneous coronary intervention

A 56-year-old male truck driver with history of percutaneous coronary intervention (PCI) to the left circumflex artery presented for worsening angina. A nuclear stress test showed a moderate reversible defect of the inferior wall. A chronic total occlusion of the mid right coronary artery with patent circumflex stent was documented by coronary angiography. After unsuccessful attempts with anterograde and retrograde wiring and dissection re-entry techniques, the subintimal tracking and re-entry (STAR) technique was utilized to advance the guidewire in an extraplaque fashion into the posterior descending artery and posterolateral branch with kissing balloon angioplasty at the bifurcation. A repeat stress test, as required by the state Department of Transportation, demonstrated a resolution of the previous reversible ischemia defect. The patient's symptoms also improved after STAR. Our case highlights an objective improvement of ischemia after STAR. • STAR with extraplaque balloon angioplasty can improve ischemia even in the absence of deferred stenting. • This could explain the reason for symptom improvement in patients after SPM and STAR. • The results from the ongoing STAR with deferred stenting study and Invest-CTO study are awaited.