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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]