AbstractBackgroundThe recent development and widespread adoption of antegrade dissection re‐entry (ADR) techniques have been underlined as one of the antegrade strategies in all worldwide CTO consensus documents. However, historical wire‐based ADR experience has suffered from disappointing long‐term outcomes.AimsCompare technical success, procedural success, and long‐term outcome of patients who underwent wire‐based ADR technique versus antegrade wiring (AW).MethodsOne thousand seven hundred and ten patients, from the prospective European Registry of Chronic Total Occlusions (ERCTO), underwent 1806 CTO procedures between January 2018 and December 2021, at 13 high‐volume ADR centers. Among all 1806 lesions attempted by the antegrade approach, 72% were approached with AW techniques and 28% with wire‐based ADR techniques.ResultsTechnical and procedural success rates were lower in wire‐based ADR than in AW (90.3% vs. 96.4%, p < 0.001; 87.7% vs. 95.4%, p < 0.001, respectively); however, wire‐based ADR was used successfully more often in complex lesions as compared to AW (p = 0.017). Wire‐based ADR was used in most cases (85%) after failure of AW or retrograde procedures. At a mean clinical follow‐up of 21 ± 15 months, major adverse cardiac and cerebrovascular events (MACCEs) did not differ between AW and wire‐based ADR (12% vs. 15.1%, p = 0.106); both AW and wire‐based ADR procedures were associated with significant symptom improvements.ConclusionsAs compared to AW, wire‐based ADR is a reliable and effective strategy successfully used in more complex lesions and often after the failure of other techniques. At long‐term follow‐up, patient's MACCEs and symptoms improvement were similar in both antegrade techniques.