TOPLINE: 

After a failed percutaneous coronary intervention (PCI) for chronic total occlusion (CTO), subintimal tracking and reentry (STAR) with the definitive stenting staged at either 5-7 weeks or 12-14 weeks was similarly safe and successful. Earlier staging more often found the vessel open at the start but did not change outcomes.

METHODOLOGY:

• Operators use STAR as a backup when a PCI for CTO is failing, and they avoid stenting right away by scheduling a staged procedure weeks later. The optimal interval between the two procedures remains uncertain, though some observational studies suggest longer gaps may help.
• Researchers conducted a prospective trial at six US centers between January 2022 and August 2024 and included 150 adults (mean age, 65.8 years; 17.3% women) who underwent PCI for CTO. STAR was used and deferred stenting was planned.
• After the first PCI, 73 patients were randomly assigned to undergo early-staged stenting at 5-7 weeks, and 77 were assigned to undergo late-staged stenting at 12-14 weeks.
• The primary endpoint was partial technical success of the staged procedure, defined as thrombolysis in myocardial infarction grade 2-3 flow with less than 30% residual stenosis into at least one distal branch ≥ 2.5 mm.
• Secondary endpoints included complete technical success, target vessel patency at the start of the staged procedure — which signified the degree to which the vessel was open — and in-hospital major cardiac and cerebral adverse events during the procedures.

TAKEAWAY:

• The rate of partial technical success was higher in the early staging group than in the late staging group (83.6% vs 71.4%), although the difference was statistically nonsignificant (P = .08).
• The early staging group had a significantly higher rate of target vessel patency at the start of the staged procedure than the late staging group (64.4% vs 44.2%; P = .04 after adjustment).
• Rates of complete technical success did not differ between groups (67.1% vs 61.0%; P = 1.00 after adjustment).
• No patient required the placement of a covered stent. Rates of in-hospital major cardiac and cerebral adverse events were similar between groups for both the index and staged procedures.

IN PRACTICE:

"These data suggest that there is no evidence of better final success with early or late repeated procedures after the STAR technique, despite greater initial patency rates with earlier interventions, and that the timing can be dictated by patient preference," the researchers wrote.

"The trial also highlights that in its current construct, CTO PCI may require 2 procedures to ensure an optimal outcome in terms of both safety and efficacy, with the potential to avoid higher-risk strategies during the initial procedure," experts wrote in an editorial comment accompanying the journal article.

SOURCE:

This study was led by Lorenzo Azzalini, MD, PhD, of University of Washington in Seattle. It was published online on November 26, 2025, in JACC.

LIMITATIONS:

The partial success rate in the late group was lower than expected, which probably reduced the power of the observed difference. The timing windows of the two groups were close, which may have limited contrast. The study did not assess long-term patency of the target vessel after the staged PCI.

DISCLOSURES:

This study received support from Asahi Intecc. Several authors reported receiving consulting fees, honoraria, grants, and/or royalties from, serving on advisory boards, and/or having other financial ties with various organizations and multiple pharmaceutical, healthcare, and medical devices companies — including Asahi Intecc, Medtronic, and Boston Scientific.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.