Antegrade dissection and re-entry vs retrograde strategy in chronic total occlusion percutaneous coronary intervention: Rationale and design of the ADRENALINE randomized study.

Opolski MP, Spiewak M, Machaj F, +15 more, Brilakis ES.

Randomized Controlled TrialOpen access

AI summary — for doctors, generated from the abstract only

The ADRENALINE trial is the first randomized study comparing antegrade dissection and re-entry versus retrograde crossing strategies for difficult chronic total occlusion PCI; this report describes its design and early enrollment progress, with results not yet available.

What was studied

A trial design report for ADRENALINE (NCT06878729), a prospective multicenter randomized superiority trial enrolling 121 patients with difficult chronic total occlusion (J-CTO score ≥2), where those with failed or unattempted antegrade wiring are randomized 1:1 to antegrade dissection and re-entry (ADR) or a retrograde crossing strategy, assessing co-primary endpoints of total procedure time and successful guidewire crossing, plus cardiac MRI-detected infarction and quality of life.

Key findings

As of June 14, 2026, 45 of the planned 121 patients had been enrolled (26 randomized, 19 observational).
This is a trial design paper; no efficacy results are presented yet.

Clinical relevance

Once completed, this trial will provide the first randomized comparative data on two commonly used "bailout" strategies for difficult chronic total occlusion PCI, which could help guide operator strategy selection; currently only design and enrollment status are available.

Who should care

Cardiology

Limitations

This is a trial design and enrollment status report; no outcome data are yet available.

A new randomized trial, ADRENALINE, comparing two advanced strategies for crossing difficult coronary blockages is underway and partially enrolled, but results are not yet available.

This is an AI-generated summary of the published abstract, not a clinical recommendation. It may not reflect the full text or subsequent updates — verify against the original source before acting on it.

Abstract

Rationale

While antegrade wiring (AW) is the most common initial strategy for chronic total occlusion (CTO) percutaneous coronary intervention (PCI), difficult CTO lesions frequently require either antegrade dissection and re-entry (ADR) or a retrograde strategy. Comparative data between ADR and the retrograde approach remain limited.

Design

The Antegrade Dissection vs Retrograde re-ENtry And Load of Interventionalist Effort (ADRENALINE) is a prospective, multicenter randomized study with a superiority design. It is planned to enroll 121 patients with difficult coronary CTO (J-CTO score ≥2) referred for CTO-PCI in accordance with the hybrid algorithm. Subjects undergoing successful AW will be included in the observational arm. Patients with failed or unattempted AW will be randomized 1:1 to ADR or retrograde CTO crossing strategy (n = 74). All patients will undergo pre- and postprocedural laboratory testing (including cardiac troponin T and creatine kinase-MB), cardiac magnetic resonance (CMR) for late gadolinium enhancement, and health status assessment by the Seattle Angina Questionnaire and the Rose Dyspnea Scale. The co-primary endpoints are total procedure time and successful guidewire crossing. Additionally, the relationship between different recanalization strategies and stress among interventional cardiologists will be explored.

Conclusion

ADRENALINE is the first randomized study of ADR vs retrograde strategy for difficult CTO PCI, assessing procedural outcomes, CMR-detected myocardial infarction, and 3-month quality of life.

Enrolment status

The first patient was enrolled on July 29, 2025. As of June 14, 2026, 45 patients (26 randomized, 19 observational) of the planned 121 patients have been enrolled.

Trials registration

Clinicaltrials.gov: Identifier, NCT06878729.

DOI

10.1016/j.ahj.2026.107538

PMID

42436000

Research metadata (titles, abstracts, authors, publication dates) is sourced from Europe PMC, which aggregates content from PubMed/MEDLINE, PubMed Central, and other providers under the U.S. National Library of Medicine (NLM/NCBI). NLM does not claim copyright on abstracts; the original journal publishers or authors may hold rights to the full articles. AI-generated summaries are derived only from the abstract, never the full text, and are always labeled as AI-generated.

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