Hybrid 2.0: Subintimal plaque modification for facilitation of future success in chronic total occlusion percutaneous coronary intervention

The Subintimal Tracking and Reentry (STAR) technique is not suitable for routine use during chronic total occlusion percutaneous coronary intervention due to side branch loss and long stent length, leading to high restenosis and re-occlusion rates. STAR without stenting (also called subintimal plaque modification [SPM]) can be used as a bailout strategy in CTO PCI, when standard crossing attempts fail. Repeat angiography is performed 2–4 months later, often showing lumen reconstitution and dissection healing, at which time the intervention can be successfully completed in many cases. Subintimal plaque modification may become an important element of the expanded hybrid algorithm. Four parameters are constantly being evaluated during the procedure: radiation dose, contrast volume, procedure time and risk of the remaining treatment options, to determine if the procedure needs to stop. Before stopping, SPM may be used to facilitate future success.