Dissection Techniques in Chronic Total Occlusion Percutaneous Coronary Intervention.

Background: There is limited data on dissection strategies in chronic total occlusion (CTO) percutaneous coronary intervention (PCI).

Objective: To study the differences in the baseline characteristics and procedural outcomes of antegrade CTO PCIs that used dissection strategies.

Methods: We performed a comparative analysis of antegrade dissection and re-entry CTO PCIs from the PROGRESS-CTO registry from 50 centers (2012-2024). Three dissection strategies were compared: (a) knuckle wiring: knuckle wire(s) without Carlino technique or CrossBoss catheter; (b) the CrossBoss technique: use of the CrossBoss catheter; and (c) the Carlino technique: use of the Carlino technique. In-stent CTO PCIs were excluded from the analysis.

Results: In total, 1575 (74.6%) cases used knuckle wiring, 427 (20.2%) the CrossBoss, and 110 (5.2%) the Carlino technique. Knuckle wiring was the most frequent strategy with increasing utilization over time (p < 0.001). The CrossBoss catheter was more common in lesions with lower J-CTO scores (CrossBoss: 2.91 vs. Knuckle wiring: 3.07 vs. Carlino: 3.18; p = 0.015), and was associated with higher technical success (CrossBoss: 84.0% vs. Knuckle wiring: 74.2% vs. Carlino: 64.2%; p < 0.001) and similar major adverse cardiac events rates, but lower perforation rates. Time to crossing was longer when Carlino was used (CrossBoss: 93 [70, 133] min vs. Knuckle wiring: 97 [63, 136] min vs. Carlino: 133 [84, 166] min, p = 0.001). Use of different types of knuckle wires (Pilot 200, Gladius Mongo, and Fielder XT) was associated with similar success rates.

Conclusions: Knuckle wiring is the most commonly used antegrade dissection strategy. The CrossBoss catheter was used in less complex cases and was associated with higher success, whereas the opposite was true for the Carlino technique.