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Background: There is limited data on predicting successful chronic total occlusion crossing using primary antegrade wiring (AW)., Objectives: The aim of this study was to develop and validate a machine learning (ML) prognostic model for successful chronic total occlusion crossing using primary AW., Methods: We used data from 12,136 primary AW cases performed between 2012 and 2023 at 48 centers in the PROGRESS CTO registry (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention; NCT02061436) to develop 5 ML models. Hyperparameter tuning was performed for the model with the best performance, and the SHAP (SHapley Additive exPlanations) explainer was implemented to estimate feature importance., Results: Primary AW was successful in 6,965 cases (57.4%). Extreme gradient boosting was the best performing ML model with an average area under the receiver-operating characteristic curve of 0.775 (± 0.010). After hyperparameter tuning, the average area under the receiver-operating characteristic curve of the extreme gradient boosting model was 0.782 in the training set and 0.780 in the testing set. Among the factors examined, occlusion length had the most significant impact on predicting successful primary AW crossing followed by blunt/no stump, presence of interventional collaterals, vessel diameter, and proximal cap ambiguity. In contrast, aorto-ostial lesion location had the least impact on the outcome. A web-based application for predicting successful primary AW wiring crossing is available online (PROGRESS-CTO website) (https://www.progresscto.org/predict-aw-success)., Conclusions: We developed an ML model with 14 features and high predictive capacity for successful primary AW in chronic total occlusion percutaneous coronary intervention., Competing Interests: Funding Support and Author Disclosures Dr Choi serves on the Advisory Board of Medtronic. Dr Poommipanit is a consultant for Asahi Intecc and Abbott Vascular. Dr Khatri has received personal honoraria for proctoring and speaking from Abbott Vascular, Medtronic, Terumo, Shockwave, and Boston Scientific. Dr Davies has received speaking honoraria from Abiomed, Asahi Intec, Boston Sci, Medtronic, Shockwave, and Teleflex; and serves on the Advisory Boards of Abiomed, Avinger, Boston Scientific, Medtronic, and Rampart. Dr Jaffer has performed sponsored research for Canon, Siemens, Shockwave, Teleflex, Mercator, and Boston Scientific; has serves as a consultant for Boston Scientific, Siemens, Magenta Medical, IMDS, Asahi Intecc, Biotronik, Philips, and Intravascular Imaging Inc; has equity interest in Intravascular Imaging Inc and DurVena; and has the right to receive royalties through Massachusetts General Hospital licensing arrangements with Terumo, Canon, and Spectrawave. Dr Jaber has received fees from Medtronic; and has received proctoring fees from Abbott. Dr Rinfret has received fees from Abbott Vascular, Abiomed, Boston Scientific, and SoundBite Medical; and has served as a consultant for Teleflex. Dr Nicholson has served as a proctor for Abbott Vascular, Boston Scientific, and Asahi Intecc; has served on the Speakers Bureau and Advisory Boards of Abbott Vascular, Boston Scientific, and Asahi Intecc; and has intellectual property with Vascular Solutions. Dr Azzalini has received consulting fees from Teleflex, Abiomed, GE Healthcare, Abbott Vascular, Reflow Medical, and Cardiovascular Systems, Inc; serves on the Advisory Boards of Abiomed and GE Healthcare; and owns equity in Reflow Medical. Dr Kearney has received consulting fees or honoraria from Asahi Intecc, Abiomed, Boston Scientific, Philips, Medtronic, Teleflex, and Reflow Medical. Dr Alaswad has served as a consultant and speaker for Boston Scientific, Abbott Cardiovascular, Teleflex, and CSI. Dr Abi-Rafeh has received proctor and speaker honoraria from Boston Scientific and Shockwave Medical. Dr Elguindy has received consulting honoraria from Medtronic, Boston Scientific, Asahi Intecc, and Terumo; and has received proctorship fees from Medtronic, Boston Scientific, Asahi Intecc, and Terumo. Dr Brilakis has received consulting/speaker honoraria from Abbott Vascular, American Heart Association (associate editor Circulation), Amgen, Asahi Intecc, Biotronik, Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), CSI, Elsevier, GE Healthcare, IMDS, Medicure, Medtronic, Siemens, Teleflex, and Terumo; has received research support from Boston Scientific and GE Healthcare; is an owner of Hippocrates LLC; and is a shareholder in MHI Ventures, Cleerly Health, and Stallion Medical. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Emergency coronary artery bypass surgery (eCABG) is a serious complication of chronic total occlusion (CTO) percutaneous coronary artery intervention (PCI)., Methods: We examined the incidence and outcomes eCABG among 14,512 CTO PCIs performed between 2012 and 2023 in a large multicenter registry., Results: The incidence of eCABG was 0.12% (n = 17). Mean age was 68 ± 6 years and 69% of the patients were men. The most common reason for eCABG was coronary perforation (70.6%). eCABG patients had larger target vessel diameter (3.36 ± 0.50 vs. 2.90 ± 0.52; p = 0.003), were more likely to have moderate/severe calcification (85.7% vs. 45.8%; p = 0.006), side branch at the proximal cap (91.7% vs. 55.4%; p = 0.025), and balloon undilatable lesions (50% vs. 7.4%; p = 0.001) and to have undergone retrograde crossing (64.7% vs. 30.8%, p = 0.006). eCABG cases had lower technical (35.3% vs. 86.7%; p < 0.001) and procedural (35.3% vs. 86.7%; p < 0.001) success and higher in-hospital mortality (35.3% vs. 0.4%; p < 0.001), coronary perforation (70.6% vs. 4.6%; p < 0.001), pericardiocentesis (47.1% vs. 0.8%; p < 0.001), and major bleeding (11.8% vs. 0.5%; p < 0.001)., Conclusions: The incidence of eCABG after CTO PCI was 0.12% and associated with high in-hospital mortality (35%). Coronary perforation was the most common reason for eCABG., Competing Interests: Declaration of competing interest Dr. Khatri: Personal Honoria for proctoring and speaking: Abbott Vascular, Medtronic, Terumo, Shockwave Medical. Dr. Jaffer has conducted sponsored research for Canon, Siemens, Shockwave, Teleflex, Mercator,Boston Scientific, HeartFlow, and Amarin; has served as a consul-tant for Boston Scientific, Siemens, Magenta Medical, International Medical Device Solutions, Asahi Intecc, Biotronik, Philips, Intravascular Imaging, and DurVena; owns equity interest in Intravascular Imaging Inc. and DurVena; and his employer, Massachusetts General Hospital, has licensing arrangements with Terumo, Canon, and Spectrawave for which he has the right to receive royalties. Dr. Davies: speaking honoraria from Abiomed, Asahi Intec, Boston Sci, Medtronic, Shockwave and Teleflex. She also serves on advisory boards for Abiomed, Avinger, Boston Sci, Medtronic and Rampart. Dr. Patel has received consulting honoraria from Abbott, Medtronic, Terumo, and Cardiovascular Systems. Dr. Sandoval: consulting/speaker honoraria from Abbott Diagnostics, Roche Diagnostics, Zoll, Philips. JACC Advances associate editor. Patent 20,210,401,347. Dr. Burke: consulting and received speaker honoraria from Abbott Vascular and Boston Scientific. Dr. Brilakis: consulting/speaker honoraria from Abbott Vascular, American Heart Association (associate editor Circulation), Biotronik, Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), CSI, Elsevier, GE Healthcare, IMDS, Medtronic, and Teleflex; research support: Boston Scientific, GE Healthcare; owner, Hippocrates LLC; shareholder: MHI Ventures, Cleerly Health, Stallion Medical., (Copyright © 2024. Published by Elsevier B.V.)

Background: The contemporary frequency and outcomes of antegrade dissection and re-entry (ADR) for chronic total occlusion (CTO) percutaneous coronary intervention (PCI) have received limited study., Objectives: The aim of this study was to determine the frequency and outcomes of ADR use in a large multicenter CTO PCI registry., Methods: The characteristics and outcomes of ADR were examined among 12,568 patients who underwent 12,841 CTO PCIs at 46 U.S. and non-U.S. centers between 2012 and 2023., Results: ADR was used in 2,385 of the procedures (18.6%). ADR use declined from 37.9% in 2012 to 14.5% in 2022 (P < 0.001). Patients in whom ADR was used had a high prevalence of comorbidities. Compared with cases that did not use ADR, ADR cases had more complex angiographic characteristics, higher mean J-CTO (Multicenter CTO Registry in Japan) score (2.94 ± 1.11 vs 2.23 ± 1.26; P < 0.001), lower technical success (77.0% vs 89.3%; P < 0.001), and higher in-hospital major adverse cardiac events (3.7% vs 1.6%; P < 0.001). The use of the CrossBoss declined from 71% in 2012 to 1.4% in 2022 and was associated with higher technical success (87%) compared with wire-based techniques (73%). The Stingray device displayed higher technical success (86%) compared with subintimal tracking and re-entry (STAR) (74%) and limited antegrade subintimal tracking (78%); however, its use has been decreasing, with STAR becoming the most used re-entry technique in 2022 (44% STAR vs 38% Stingray)., Conclusions: The use of ADR has been decreasing. ADR was used in more complex lesions and was associated with lower technical success and higher major adverse cardiac events compared with non-ADR cases. There has been a decrease in Stingray use and an increase in the use of STAR for re-entry., Competing Interests: Funding Support and Author Disclosures Dr Ybarra is a consultant for SoundBite Medical; and has received speaker honoraria for Abbott Vascular. Dr Rinfret is a consultant for Boston Scientific, Teleflex, Abbott Vascular, Biotronik, and SoundBite Medical; has received fees from Abbott Vascular, Abiomed, Boston Scientific, and SoundBite Medical; and has been a consultant for Teleflex. Dr Choi is an advisory board member for Medtronic. Dr Poommipanit is a consultant for Asahi Intecc and Abbott Vascular. Dr Khatri has received personal honoraria for proctoring and speaking from Abbott Vascular, Medtronic, Terumo, Shockwave, and Boston Scientific. Dr Davies has received speaking honoraria from Abiomed, Asahi Intecc, Boston Scientific, Medtronic, Shockwave and Teleflex; and serves on advisory boards for Abiomed, Avinger, Boston Scientific, Medtronic, and Rampart. Dr Jaffer has conducted sponsored research for Canon, Siemens, Shockwave, Teleflex, Mercator, and Boston Scientific; has been a consultant for Boston Scientific, Siemens, Magenta Medical, IMDS, Asahi Intecc, Biotronik, Philips, and Intravascular Imaging; has equity interest in Intravascular Imaging and DurVena; and has the right to receive royalties through Massachusetts General Hospital licensing arrangements with Terumo, Canon, and SpectraWAVE. Dr Jaber has received consulting fees from Medtronic; and has received proctoring fees from Abbott. Dr Nicholson has been a proctor and a Speakers Bureau and advisory board member for Abbott Vascular, Boston Scientific, and Asahi Intecc; and has intellectual property with Vascular Solutions. Dr Azzalini has received consulting fees from Teleflex, Abiomed, GE Healthcare, Asahi Intecc, Philips, Abbott Vascular, Reflow Medical, and Cardiovascular Systems. Dr Alaswad has been a consultant and speaker for Boston Scientific, Abbott Cardiovascular, Teleflex, and Cardiovascular Systems. Dr Abi-Rafeh has received proctor and speaker honoraria from Boston Scientific and Shockwave Medical. Dr ElGuindy has received consulting honoraria from Medtronic, Boston Scientific, Asahi Intecc, and Terumo; and has received proctorship fees from Medtronic, Boston Scientific, Asahi Intecc, and Terumo. Dr Allana is a consultant for Abiomed and Boston Scientific. Dr Brilakis has received consulting and speaker honoraria from Abbott Vascular, the American Heart Association (associate editor, Circulation), Amgen, Asahi Intecc, Biotronik, Boston Scientific, the Cardiovascular Innovations Foundation (Board of Directors), Cardiovascular Systems, Elsevier, GE Healthcare, IMDS, Medicure, Medtronic, Siemens, Teleflex, and Terumo; has received research support from Boston Scientific and GE Healthcare; is an owner of Hippocrates; and is a shareholder in MHI Ventures, Cleerly Health, and Stallion Medical. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Retrograde chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is associated with lower success and higher complication rates when compared with the antegrade approach., Objectives: This study sought to assess contemporary techniques and outcomes of retrograde CTO PCI., Methods: We examined the baseline characteristics, procedural techniques and outcomes of 4,058 retrograde CTO PCIs performed at 44 centers between 2012 and 2023. Major adverse cardiac events (MACE) included any of the following in-hospital events: death, myocardial infarction, repeat target vessel revascularization, pericardiocentesis, cardiac surgery, and stroke., Results: The average J-CTO (Multicenter CTO Registry in Japan) score was 3.1 ± 1.1. Retrograde crossing was successful in 60.5% and lesion crossing in 81.6% of cases. The collaterals pathways successfully used were septals in 62.0%, saphenous vein grafts in 17.4%, and epicardials in 19.1%. The technical and procedural success rates were 78.7% and 76.6%, respectively. When retrograde crossing failed, technical success was achieved in 50.3% of cases using the antegrade approach. In-hospital MACE was 3.5%. The clinical coronary perforation rate was 5.8%. The incidence of in-hospital MACE with retrograde true lumen crossing, just marker antegrade crossing, conventional reverse controlled antegrade and retrograde tracking (CART), contemporary reverse CART, extended reverse CART, guide-extension reverse CART, and CART was 2.1%, 0.8%, 5.5%, 3.0%, 2.1%, 3.2%, and 4.1%, respectively; P = 0.01)., Conclusions: Retrograde CTO PCI is utilized in highly complex cases and yields moderate success rates with 5.8% perforation and 3.5% periprocedural MACE rates. Among retrograde crossing strategies, retrograde true lumen puncture was the safest. There is need for improvement of the efficacy and safety of retrograde CTO PCI., Competing Interests: Funding Support and Author Disclosures The Minneapolis Heart Institute Foundation; Science Center for Coronary Artery Disease (CCAD) helped support this research project. Study data were collected and managed using Research Electronic Data Capture. (REDCap) electronic data capture tools hosted at the Minneapolis Heart Institute Foundation (MHIF), Minneapolis, Minnesota. Dr Allana has been a consultant for Boston Scientific and Abiomed. D. Choi has received speaking honoraria from Shockwave. Dr Alaswad has been a consultant and speaker for Boston Scientific, Abbott Cardiovascular, Teleflex, and Cardiovascular Systems Inc. Dr Davies has received speaking honoraria from Abiomed, Asahi Intec, Boston Scientific, Medtronic, Siemens Healthineers, Shockwave, and Teleflex; and has served on advisory boards for Abiomed, Boston Scientific, Medtronic, and Rampart. Dr Karmpaliotis has received honoraria from Boston Scientific, Abbott Vascular, Abiomed; Equity: Saranas, Soundbite, and Traverse Vascular. Dr Jaffer has received research funding from Canon, Siemens, Shockwave, Teleflex, Mercator, Boston Scientific, HeartFlow, and Amarin; has been a consultant for Boston Scientific, Siemens, Magenta Medical, International Medical Device Solutions, Asahi Intecc, Biotronik, Philips, Intravascular Imaging, and DurVena; holds equity interest in Intravascular Imaging Inc, Massachusetts General Hospital, and DurVena; and has licensing arrangements with Terumo, Canon, and Spectrawave, for which he hast he right to receive royalties. Dr Khatri has received honoraria for proctoring and speaking from Abbott Vascular, Medtronic, Terumo, and Shockwave Medical. Dr Poommipanit has been a consultant for Medtronic, Asahi Intecc, and Abbott Vascular. Dr Azzalini has received consulting fees from Teleflex, Abiomed, GE Healthcare, Asahi Intecc, Philips, Abbott Vascular, Reflow Medical, and Cardiovascular Systems, Inc. Dr Nicholson has been a proctor and is on Speakers Bureau and advisory boards for Abbott Vascular, Boston Scientific, and Asahi Intecc; and holds intellectual property with Vascular Solutions. Dr Jaber has received consulting fees from Inari Medical and Medtronic. Dr Rinfret has been a consultant for Boston Scientific, Teleflex, Medtronic, Abbott, and Abiomed. Dr Brilakis has received consulting/speaker honoraria from Abbott Vascular, American Heart Association (as associate editor of Circulation), Amgen, Asahi Intecc, Biotronik, Boston Scientific, Cardiovascular Innovations Foundation (board of directors), ControlRad, CSI, Elsevier, GE Healthcare, IMDS, InfraRedx, Medicure, Medtronic, Opsens, Siemens, and Teleflex; has received research support from Boston Scientific and GE Healthcare; is the owner of Hippocrates LLC; and is a shareholder in MHI Ventures, Cleerly Health, and Stallion Medical. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Coronary calcification is common and increases the difficulty of chronic total occlusion (CTO) percutaneous coronary intervention (PCI)., Methods: We examined the impact of calcium on procedural outcomes of 13,079 CTO PCIs performed in 12,799 patients at 46 US and non-US centers between 2012 and 2023., Results: Moderate or severe calcification was present in 46.6% of CTO lesions. Patients whose lesions were calcified were older and more likely to have had prior coronary artery bypass graft surgery. Calcified lesions were more complex with higher J-CTO score (3.0 ± 1.1 vs. 1.9 ± 1.2; p < 0.001) and lower technical (83.0% vs. 89.9%; p < 0.001) and procedural (81.0% vs. 89.1%; p < 0.001) success rates compared with mildly calcified or non-calcified CTO lesions. The retrograde approach was more commonly used among cases with moderate/severe calcification (40.3% vs. 23.5%; p < 0.001). Balloon angioplasty (76.6%) was the most common lesion preparation technique for calcified lesions, followed by rotational atherectomy (7.3%), laser atherectomy (3.4%) and, intravascular lithotripsy (3.4%). The incidence of major adverse cardiovascular events (MACE) was higher in cases with moderate or severe calcification (3.0% vs. 1.2%; p < 0.001), as was the incidence of perforation (6.5% vs. 3.4%; p < 0.001). On multivariable analysis, the presence of moderate/severe calcification was independently associated with lower technical success (odds ratio, OR = 0.73, 95% CI: 0.63-0.84) and higher MACE (OR = 2.33, 95% CI: 1.66-3.27)., Conclusions: Moderate/severe calcification was present in nearly half of CTO lesions, and was associated with higher utilization of the retrograde approach, lower technical and procedural success rates, and higher incidence of in-hospital MACE., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Objectives: To examine gender disparities in genitourinary (GU) oncology academic publishing over the past three decades., Materials and Methods: We performed a bibliometric analysis of eight academic journals featuring GU oncology research articles: Journal of Clinical Oncology, Cancer, European Journal of Cancer, European Urology, Journal of Urology, BJU International, Prostate Cancer and Prostatic Diseases, and Urologic Oncology: Seminars and Original Investigations. After selecting four time points (1990, 2000, 2010, 2020), we recorded the gender of the first and senior authors and investigated their association with independent variables including publication year, research field, and geographic continent. Results were expressed as odds ratios (ORs) and 95% confidence intervals (CIs)., Results: A total of 14,786 articles were included in our analyses. Females comprised 25.7% of first and 18.1% of senior authors. Compared to 1990, there was a trend of progressively higher female first author (OR 1.47 [95% CI 1.27-1.69] in 2000; 2.28 [95% CI 2.00-2.59] in 2010; 3.10 [95% CI 2.71-3.55] in 2020) and senior author positions (OR 1.23 [95% CI 1.05-1.45] in 2000; 1.67 [95% CI 1.45-1.93] in 2010; 2.55 [95% CI 2.20-2.96] in 2020). Compared to GU oncology, non-GU oncology articles were more likely to have female first (OR 2.61, 95% CI 2.38-2.86) or senior authors (OR 2.61, 95% CI 2.35-2.91). Articles from Asia (OR 0.45, 95% CI 0.38-0.51), Africa (OR 0.45, 95% CI 0.22-0.91), and international collaborations (OR 0.62, 95% CI 0.50-0.76) had a lower proportion of female first authors compared to North America. First authors were significantly more likely to be female when senior authors were also female (OR 2.45, 95% CI 2.23-2.69)., Conclusions: Despite the bridging trend demonstrated, GU oncology remains a male-predominant discipline. Female leadership and mentorship are pivotal in achieving gender parity in the academic medicine community., Competing Interests: Declaration of Competing Interest PM has received honoraria for service on a Scientific Advisory Board for Mirati Therapeutics BMS, and Exelixis; consulting for Axiom Healthcare Strategies; non-branded educational programs supported by Exelixis and Pfizer; and research funding for clinical trials from Takeda, BMS, Mirati Therapeutics, Gateway for Cancer Research, and UT MD Anderson Cancer Center. All other authors report no conflict of interest., (Copyright © 2023 Elsevier Inc. All rights reserved.)