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A 66-year-old man with a ramus chronic total occlusion had escalating angina and a high-risk stress test. Coronary angiography the day of his planned ramus chronic total occlusion percutaneous coronary intervention demonstrated a large left main aneurysm. He underwent bypass with left internal mammary artery left anterior descending and failed saphenous vein graft ramus, followed by successful covered stent placement from left main into left circumflex and ramus chronic total occlusion percutaneous coronary intervention. (Level of Difficulty: Advanced.)

Background: Balloon uncrossable lesions are defined as lesions that cannot be crossed with a balloon after successful guidewire crossing. Methods: We analyzed the association between balloon uncrossable lesions and procedural outcomes of 8671 chronic total occlusions (CTOs) percutaneous coronary interventions (PCIs) performed between 2012 and 2022 at 41 centers. Results: The prevalence of balloon uncrossable lesions was 9.2%. The mean patient age was 64.2 ± 10 years and 80% were men. Patients with balloon uncrossable lesions were older (67.3 ± 9 vs. 63.9 ± 10, p < 0.001) and more likely to have prior coronary artery bypass graft surgery (40% vs. 25%, p < 0.001) and diabetes mellitus (50% vs. 42%, p < 0.001) compared with patients who had balloon crossable lesions. In-stent restenosis (23% vs. 16%. p < 0.001), moderate/severe calcification (68% vs. 40%, p < 0.001), and moderate/severe proximal vessel tortuosity (36% vs. 25%, p < 0.001) were more common in balloon uncrossable lesions. Procedure time (132 (90, 197) vs. 109 (71, 160) min, p < 0.001) was longer and the air kerma radiation dose (2.55 (1.41, 4.23) vs. 1.97 (1.10, 3.40) min, p < 0.001) was higher in balloon uncrossable lesions, while these lesions displayed lower technical (91% vs. 99%, p < 0.001) and procedural (88% vs. 96%, p < 0.001) success rates and higher major adverse cardiac event (MACE) rates (3.14% vs. 1.49%, p < 0.001). Several techniques were required for balloon uncrossable lesions. Conclusion: In a contemporary, multicenter registry, 9.2% of the successfully crossed CTOs were initially balloon uncrossable. Balloon uncrossable lesions exhibited lower technical and procedural success rates and a higher risk of complications compared with balloon crossable lesions. [ABSTRACT FROM AUTHOR]

Aim To examine the impact of diabetes mellitus on procedural outcomes of patients who underwent percutaneous coronary intervention for chronic total occlusion. Methods We assessed the impact of diabetes mellitus on the outcomes of percutaneous coronary intervention for chronic total occlusion among 1308 people who underwent such procedures at 11 US centres between 2012 and 2015. Results The participants' mean ± sd age was 66 ± 10 years, 84% of the participants were men and 44.6% had diabetes. As compared with participants without diabetes, participants with diabetes were more likely to have undergone coronary artery bypass graft surgery (38 vs 31%; P = 0.006), and to have had previous heart failure (35 vs 22%; P = 0.0001) and peripheral arterial disease (19 vs 13%; P = 0.002). They also had a higher BMI (31 ± 6 kg/m2 vs 29 ± 6 kg/m2; P = 0.001), similar Japanese chronic total occlusion scores (2.6 ± 1.2 vs 2.5 ± 1.2; P = 0.82) and similar final successful crossing technique: antegrade wire escalation (46 vs 47%; P = 0.66), retrograde (30 vs 28%; P = 0.66) and antegrade dissection re-entry (24 vs 25%; P = 0.66). Technical (91 vs 90%; P = 0.80) and procedural (89 vs 89%; P = 0.93) success was similar in the two groups, as was the incidence of major adverse cardiac events (2.2 vs 2.5%; P = 0.61). Conclusions In a contemporary cohort of people undergoing percutaneous coronary intervention for chronic total occlusion, nearly one in two (45%) had diabetes mellitus. Procedural success and complication rates were similar in people with and without diabetes. [ABSTRACT FROM AUTHOR]

Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is associated with a considerable risk of complications, and risk stratification is of utmost importance. To assess the clinical usefulness of the recently developed PROGRESS-CTO (NCT02061436) complication risk scores in an independent cohort. Individual patient data pooled analysis of 3 registries was performed. Of the 4569 patients who underwent CTO PCI, 102 (2.2%) had major adverse cardiovascular events (MACE). Patients with MACE were older (69 ± 11 vs. 65 ± 10, p < 0.001), more likely to have a history of prior coronary artery bypass graft surgery, and unfavorable angiographic characteristics J-CTO score (2.4 ± 1.2 vs. 2.1 ± 1.3, p = 0.007), including blunt stump (59% vs. 49%, p = 0.047). Technical success was lower in patients with MACE (59% vs. 86%, p < 0.001). The area under the receiver operating characteristic curve of the PROGRESS-CTO complication risk models were as follows: MACE 0.72 (95% confidence interval [CI], 0.67–0.76), mortality 0.73 (95% CI, 0.61–0.85), and pericardiocentesis 0.69 (95% CI, 0.62–0.77) in the validation dataset. The observed complication rates increased with higher PROGRESS-CTO complication scores. The PROGRESS-CTO MACE score showed good calibration in this external cohort, with MACE rates similar to the original study: 0.7% (score 0–1), 1.5% (score 2), 2.2% (score 3), 3.8% (score 4), 4.9% (score 5), 5.8% (score 6–7). Given the good discriminative performance, calibration, and ease of calculation, the PROGRESS-CTO complication scores could help assess the risk of complications in patients undergoing CTO PCI. • We evaluated the PROGRESS-CTO complication risk scores in an individual patient data pooled analysis of 3 CTO PCI registries. • The c-statistic of the models were 0.72, 0.73, and 0.69 for MACE, mortality, and pericardiocentesis, respectively. • The use of the PROGRESS-CTO complication risk should be considered to facilitate risk-benefit assessment in CTO PCI. [ABSTRACT FROM AUTHOR]

Preprocedural coronary computed tomography angiography (CCTA) can be useful in procedural planning for chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We examined the clinical, angiographic and procedural characteristics and outcomes of cases with vs. without preprocedural CCTA in PROGRESS-CTO (NCT02061436). Multivariable logistic regression was used to adjust for confounding factors. Of 7034 CTO PCI cases, preprocedural CCTA was used in 375 (5.3%) with increasing frequency over time. Patients with preprocedural CCTA had a higher prevalence of prior coronary artery bypass graft surgery (39% vs. 27%, p < 0.001) and angiographically unfavorable characteristics including higher prevalence of proximal cap ambiguity (52% vs. 33%, p < 0.001) and moderate/severe calcification (59% vs. 41%, p < 0.001) compared with those without CCTA. CCTA helped resolve proximal cap ambiguity in 27%, identified significant calcium not seen on diagnostic angiography in 18%, changed estimated CTO length by >5 mm in 10%, and was performed as part of initial coronary artery disease work up in 19%. CCTA cases had higher J-CTO (2.6 ± 1.2 vs. 2.3 ± 1.3, p < 0.001) and PROGRESS-CTO (1.3 ± 1.0 vs. 1.2 ± 1.0 p = 0.027) scores. After adjusting for potential confounders, cases with preprocedural CCTA had similar technical success (odds ratio [OR]: 1.18, 95% confidence interval [CI], 0.83–1.67) and incidence of major adverse cardiovascular events (OR: 1.47, 95% CI, 0.72–3.00). Preprocedural CCTA was used in ~5% of CTO PCI cases. While CCTA may help with procedural planning, especially in complex cases, technical success and MACE were similar with or without CCTA. • Of the 7,034 CTO PCI procedures performed between 2012-2022, preprocedural CCTA was used in 375 (5.3%). • CCTA helped resolve proximal cap ambiguity in 27%, identified calcium in 18%, and changed the estimated CTO length in 10%. • On multivariable analysis preprocedural CCTA was not associated with technical success or major adverse cardiovascular events. [ABSTRACT FROM AUTHOR]

Background A hybrid approach to chronic total occlusion (CTO) percutaneous coronary intervention (PCI) prioritizing and combining all available crossing techniques was developed to optimize procedural efficacy, efficiency, and safety, but there is limited published data on its outcomes. Methods We examined the procedural techniques and outcomes of 1036 consecutive CTO PCIs performed using a hybrid approach between 2012 and 2015 at 11 US centers. Results Mean age was 65 ± 10 years and 86% of the patients were men, with a high prevalence of diabetes mellitus (43%) and prior coronary artery bypass graft surgery (34%). Most target CTOs were located in the right coronary artery (59%), followed by the left anterior descending artery (23%) and the circumflex (19%). Dual injection was used in 71%. Technical success was achieved in 91% and a major procedural complication occurred in 1.7% of cases. The final successful crossing technique was antegrade wire escalation in 46%, antegrade dissection/re-entry in 26%, and retrograde in 28%. The initial crossing strategy was successful in 58% of the lesions, whereas 39% required an additional approach. Overall, antegrade wire escalation was used in 71%, antegrade dissection/re-entry in 36%, and the retrograde approach in 42% of procedures. Median contrast volume, fluoroscopy time, and air kerma radiation dose were 260 (200–360) ml, 44 (27–72) min, and 3.4 (2.0–5.4) Gray, respectively. Conclusion Application of a hybrid approach to CTO crossing resulted in high success and low complication rates across a varied group of operators and hospital practice structures, supporting its expanding use in CTO PCI. [ABSTRACT FROM AUTHOR]

The prevalence, treatment, and outcomes of balloon undilatable lesions encountered in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) have received limited study. We examined the clinical characteristics and procedural outcomes of balloon undilatable lesions in the Prospective Global Registry for the Study of CTO Intervention (PROGRESS-CTO, NCT02061436). Of 6535 CTO PCIs performed between 2012 and 2022, 558 (8.5%) lesions were balloon undilatable. In this subset, patients were older (mean age 67 ± 10 vs. 64 ± 10, p < 0.001) and had higher prevalence of comorbidities: diabetes mellitus (54% vs. 40%, p < 0.001), prior PCI (71% vs. 59%, p < 0.001), prior myocardial infarction (52% vs. 45%, p = 0.003), and prior coronary artery bypass graft surgery (44% vs. 25%, p < 0.001). The CTO lesion length was estimated to be 34 ± 23 mm, mean J-CTO score was 2.9 ± 1.1 and mean PROGRESS-CTO score was 1.4 ± 1.0. A cutting balloon was used in 27%, a scoring balloon in 15%, laser in 14%, rotational atherectomy in 28%, orbital atherectomy in 10%, intravascular lithotripsy in 1% and other modalities/approaches in 5%. Balloon undilatable lesions had lower technical success (90.9% vs. 93.8%, p = 0.007) and higher incidence of major adverse cardiovascular events (MACE) (composite of in-hospital death, acute myocardial infarction, stroke, re-PCI, emergency CABG, and pericardiocentesis) (5.0% versus 1.3%, p < 0.001). Approximately 1 in 12 CTO (8.5%) lesions are balloon undilatable. Treatment of balloon undilatable lesions is associated with lower technical success and higher in-hospital MACE. • Approximately 1/12 chronic total occlusion (8.5%) lesions are balloon undilatable • Balloon undilatable lesions had lower technical success (90.9% vs. 93.8%, p = 0.007) • Balloon undilatable lesions had higher MACE (5.0% versus 1.3%, p < 0.001) [ABSTRACT FROM AUTHOR]

Saphenous vein grafts (SVGs) remain the most frequently used conduits in coronary artery bypass graft surgery (CABG). Despite advances in surgical techniques and pharmacotherapy, SVG failure rates remain high, often leading to repeat coronary revascularization. The no-touch SVG harvesting technique (minimal graft manipulation with preservation of vasa vasorum and nerves) reduces the risk of SVG failure, whereas the effect of the off-pump technique on SVG patency remains unclear. Use of buffered storage solutions, intraoperative graft flow measurement, careful selection of the target vessels, and physiological assessment of the native coronary circulation before CABG may also reduce the incidence of SVG failure. Perioperative aspirin and high-intensity statin administration are the cornerstones of secondary prevention after CABG. Dual antiplatelet therapy is recommended for off-pump CABG and in patients with a recent acute coronary syndrome. Intermediate (30%-60%) SVG stenoses often progress rapidly. Stenting of intermediate SVG stenoses failed to improve outcomes; hence, treatment focuses on strict control of coronary artery disease risk factors. Redo CABG is associated with higher perioperative mortality compared with percutaneous coronary intervention (PCI); hence, the latter is preferred for most patients requiring repeat revascularization after CABG. SVG PCI is limited by high rates of no-reflow and a high incidence of restenosis during follow-up. Drug-eluting and bare metal stents provide similar long-term outcomes in SVG PCI. Embolic protection devices reduce no-reflow and should be used when feasible. PCI of the corresponding native coronary artery is associated with better short- and long-term outcomes and is preferred over SVG PCI, if technically feasible. [ABSTRACT FROM AUTHOR]

Coronary calcification is common and increases the difficulty of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). 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. 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). 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. • Moderate/severe calcification: • is present in nearly half of chronic total occlusion (CTO) lesions • requires more frequent use of the retrograde approach • requires more frequent use of intravascular ultrasound (IVUS) and advanced plaque modification techniques • is associated with lower technical and procedural success, and higher major adverse cardiovascular events (MACE) [ABSTRACT FROM AUTHOR]

Background: Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) evolves rapidly over time. The hybrid approach to CTO PCI is a crossing algorithm that emphasizes dual coronary injection, structured review of the angiogram, and change of crossing strategies in case of failure. Methods: We analyzed the contemporary outcomes from the PROGRESS CTO registry by analyzing the clinical, angiographic and procedural characteristics of 3,571 CTO interventions performed in 3,503 patients enrolled between 2012 and 2018 at 21 centers. Results: Mean patient age was 65±10 years and 85% of the patients were men. A high prevalence of diabetes (42%), heart failure (31%), prior coronary artery bypass graft surgery (32%), prior myocardial infarction (47%), and prior PCI (65%) was observed. The most common CTO target vessel was the right coronary artery (56%), left anterior descending artery (24%), and left circumflex artery (19%). Mean J-CTO and PROGRESS-CTO scores were 2.4±1.3 and 1.3±1.0, respectively. The final successful crossing strategy was antegrade wire escalation in 53%, retrograde in 27%, and antegrade dissection re-entry in 20%. The initial crossing strategy was successful in 56%, however using multiple approaches (Figure), the overall technical and procedural success rate was 87% and 85%, respectively. In-hospital major complications were 2.9%, and consisted of death [0.8%], acute myocardial infarction [1.0%], stroke [0.3%], tamponade requiring pericardiocentesis [0.9%], emergency surgery [0.1%] and repeat PCI [0.3%]. Median contrast volume, air kerma radiation dose, procedure and fluoroscopy time were 260 (194-350) ml, 2.8 (1.6-4.7) Gray, 120 (78-184) and 46 (28-76) minutes, respectively. Conclusions: The hybrid approach to CTO PCI is associated with high overall success and acceptable complication rates in diverse patient populations. [ABSTRACT FROM AUTHOR]

Introduction: The retrograde approach is critical for achieving high success rates in chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Methods: We compared the clinical, angiographic and procedural outcomes of retrograde (n=1,350) vs. antegrade-only CTO PCIs (n=2,221) in a contemporary multicenter CTO registry. Results: The mean age of patients undergoing retrograde PCI was 65±10 years and 86% were men, with high prevalence of prior myocardial infarction (51%), prior PCI (71%), and coronary artery bypass graft surgery (45%). CTO target vessels with the retrograde approach was the right coronary artery (68%), left anterior descending artery (16%), and left circumflex artery (15%). Lesions undergoing retrograde attempt were longer (42±27 mm vs 28±19 mm, p<0.001), and more likely to have proximal cap ambiguity (54% vs 25%), distal cap at bifurcation (47% vs 25%), diseased distal target vessel (46% vs 24%, p<0.001), and interventional collaterals (79% vs 45%, p<0.001), as compared with antegrade-only cases. The mean J-CTO (3±1 vs 2±1 p<0.001) and PROGRESS CTO complication score (4±2 vs 2±2, p<0.001) was higher in retrograde PCIs. The most commonly used collateral channels were septals (61%), epicardials (33%), saphenous venous grafts (13%) and left internal mammary artery grafts (2%). As lesion complexity increased, successful retrograde crossing was more frequently needed (Figure). The overall technical (81% vs 91%, p<0.001) and procedural (77% vs 90%, p<0.001) success rates were lower with retrograde approach, and patients had higher in-hospital major complications rate than antegrade-only PCIs (5.6% vs 1.1%, p<0.001), due to higher in-hospital mortality (1.5% vs. 0.3%, p<0.001), acute myocardial infarction (2.1% vs 0.3%, p<0.001), repeat PCI (0.7% vs 0.1%, p<0.001), and tamponade requiring pericardiocentesis (1.7% vs 0.3%, p<0.01). Conclusions: The retrograde approach to CTO PCI is commonly required among more complex lesions, which likely explains why it is associated with lower procedural success and higher complication rates. [ABSTRACT FROM AUTHOR]

Background We assessed efficacy and safety of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) using antegrade dissection re-entry (ADR). Methods We examined outcomes of ADR among 1313 CTO PCIs performed at 11 US centers between 2012–2015. Results 84.1% of patients were men. Prevalence of prior coronary artery bypass graft surgery was 34.3%. Overall technical and procedural success were 90.1% and 88.7%, respectively. In-hospital major adverse cardiovascular events (MACE) occurred in 31 patients (2.4%). ADR was used in 458 cases (34.9%), and was the first strategy in 169 cases (12.9%). ADR cases were angiographically more complex than non-ADR cases (mean J-CTO score: 2.8 ± 1.2 vs. 2.4 ± 1.2, p < 0.001). ADR was performed using the CrossBoss catheter in 246 of 458 (53.7%) and the Stingray system in 251 ADR cases (54.8%). Compared with non-ADR cases, ADR cases had lower technical (86.9% vs. 91.8%, p = 0.005) and procedural success (85.0% vs. 90.7%, p = 0.002), but similar risk for MACE (2.9% vs. 2.2%, p = 0.42). ADR was associated with longer procedure and fluoroscopy time, and higher patient air kerma dose and contrast volume (all p < 0.001). After excluding retrograde cases, ADR and antegrade wire escalation (AWE) had similar technical success (92.7% vs. 94.2%, p = 0.43), procedural success (91.8% vs. 94.1%, p = 0.23), and MACE (2.1% vs. 0.6%, p = 0.12). Conclusions ADR is used relatively frequently in contemporary CTO PCI, especially for challenging lesions and after failure of other strategies. ADR is associated with similar success rates and risk for complications as compared with AWE, and is important for achieving high procedural success. [ABSTRACT FROM AUTHOR]

Percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs) has been traditionally associated with lower success rates in patients with previous coronary artery bypass graft surgery (CABG). We sought to examine the success and complication rates of CTO PCI using the "hybrid" crossing algorithm among patients with a history of previous CABG. The procedural outcomes of 496 consecutive CTO PCIs performed at 5 high-volume PCI centers in the United States from January 2012 to August 2013 were assessed. The outcomes of patients with previous CABG were compared with those of patients without previous CABG.Compared with patients without previous CABG (n = 320), patients with previous CABG (n = 176, 35%) were older, had more coronary artery disease risk factors, and had less favorable baseline angiographic CTO characteristics. Technical and procedural success was slightly lower among patients with previous CABG (88.1% vs 93.4%, p = 0.044 and 87.5 vs 92.5%, p = 0.07, respectively). Patients with previous CABG more commonly underwent CTO PCI using the retrograde approach (39% vs 24%, respectively, p <0.001) and received higher air kerma radiation exposure (4.8 =interquartile range 3.0 to 6.4] vs 3.1 =1.9 to 5.3] Gray, p <0.001) and fluoroscopy time (59 =38 to 77] vs 34 =21 to 55] minutes, p <0.001). Major procedural complications were similar in the 2 groups: 2 of 176 (1.1%) patients with previous CABG versus 7 of 320 (2.1%) patients without previous CABG (p = 0.40). In conclusion, with application of the "hybrid" approach to CTO PCI, success was slightly lower, and complication rates were similar between patients with and without previous CABG. [ABSTRACT FROM AUTHOR]