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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: Antegrade wiring is the most commonly used chronic total occlusion (CTO) crossing technique., Methods: Using data from the PROGRESS CTO registry (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention; Clinicaltrials.gov identifier: NCT02061436), we examined the clinical and angiographic characteristics and procedural outcomes of CTO percutaneous coronary interventions (PCIs) performed using a primary antegrade wiring strategy., Results: Of the 13 563 CTO PCIs performed at 46 centers between 2012 and 2023, a primary antegrade wiring strategy was used in 11 332 (83.6%). Upon multivariable logistic regression analysis, proximal cap ambiguity (odds ratio [OR]: 0.52; 95% CI, 0.46-0.59), side branch at the proximal cap (OR: 0.85; 95% CI, 0.77-0.95), blunt/no stump (OR: 0.52; 95% CI: 0.47-0.59), increasing lesion length (OR [per 10 mm increase]: 0.79; 95% CI, 0.76-0.81), moderate to severe calcification (OR: 0.73; 95% CI, 0.66-0.81), moderate to severe proximal tortuosity (OR: 0.67; 95% CI, 0.59-0.75), bifurcation at the distal cap (OR: 0.66; 95% CI, 0.59-0.73), left anterior descending artery CTO (OR [vs right coronary artery]: 1.44; 95% CI, 1.28-1.62) and left circumflex CTO (OR [vs right coronary artery]: 1.22; 95% CI, 1.07-1.40), non-in-stent restenosis lesion (OR: 0.56; 95% CI, 0.49-0.65), and good distal landing zone (OR: 1.18; 95% CI, 1.06-1.32) were independently associated with primary antegrade wiring crossing success., Conclusions: The use of antegrade wiring as the initial strategy was high (83.6%) in our registry. We identified several parameters associated with primary antegrade wiring success.

Background: The complex high-risk indicated percutaneous coronary intervention (CHIP) score is a tool developed using the British Cardiovascular Intervention Society (BCIS) database to define CHIP cases and predict in-hospital major adverse cardiac or cerebrovascular events (MACCE)., Aim: To assess the validity of the CHIP score in chronic total occlusion (CTO) percutaneous coronary intervention (PCI)., Methods: We evaluated the performance of the CHIP score on 8341 CTO PCIs from the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO) performed at 44 centers between 2012 and 2023., Results: In our cohort, 7.8% (n = 647) of patients had a CHIP score of 0, 50.2% (n = 4192) had a CHIP score of 1-2, 26.2% (n = 2187) had a CHIP score of 3-4, 11.7% (n = 972) had a CHIP score of 5-6, 3.3% (n = 276) had a CHIP score of 7-8, and 0.8% (n = 67) had a CHIP score of 9+. The incidence of MACCE for a CHIP score of 0 was 0.6%, reaching as high as 8.7% for a CHIP score of 9+, confirming that a higher CHIP score is associated with a higher risk of MACCE. The estimated increase in the risk of MACCE per one score unit increase was 100% (95% confidence interval [CI]: 65%-141%). The AUC of the CHIP score model for predicting MACCE in our cohort was 0.63 (95% CI: 0.58-0.67). There was a positive correlation between the CHIP score and the PROGRESS-CTO MACE score (Spearman's correlation: 0.37; 95% CI: 0.35-0.39; p < 0.001)., Conclusions: The CHIP score has modest predictive capacity for MACCE in CTO PCI., (© 2024 Wiley Periodicals LLC.)

Background: There is limited data on retrograde chronic total occlusion (CTO) percutaneous coronary intervention (PCI) via ipsilateral epicardial collaterals (IEC)., Aims: To compare the clinical and angiographic characteristics, and outcomes of retrograde CTO PCI via IEC versus other collaterals in a large multicenter registry., Methods: Observational cohort study from the Prospective Global registry for the study of Chronic Total Occlusion Intervention (PROGRESS-CTO)., Results: Of 4466 retrograde cases performed between 2012 and 2023, crossing through IEC was attempted in 191 (4.3%) cases with 50% wiring success. The most common target vessel in the IEC group was the left circumflex (50%), in comparison to other retrograde cases, where the right coronary artery was most common (70%). The Japanese CTO score was similar between the two groups (3.13 ± 1.23 vs. 3.06 ± 1.06, p = 0.456); however, the IEC group had a higher Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO) score (1.95 ± 1.02 vs. 1.27 ± 0.92, p < 0.0001). The most used IEC guidewire was the SUOH 03 (39%), and the most frequently used microcatheter was the Caravel (43%). Dual injection was less common in IEC cases (66% vs. 89%, p < 0.0001). Technical (76% vs. 79%, p = 0.317) and procedural success rates (74% vs. 79%, p = 0.281) were not different between the two groups. However, IEC cases had a higher procedural complications rate (25.8% vs. 16.4%, p = 0.0008), including perforations (17.3% vs. 9.0%, p = 0.0001), pericardiocentesis (3.1% vs. 1.2%, p = 0.018), and dissection/thrombus of the donor vessel (3.7% vs. 1.2%, p = 0.002)., Conclusion: The use of IEC for retrograde CTO PCI was associated with similar technical and procedural success rates when compared with other retrograde cases, but higher incidence of periprocedural complications., (© 2024 Wiley Periodicals LLC.)

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: There is limited data on the use of the balloon-assisted subintimal entry (BASE) technique in chronic total occlusion (CTO) percutaneous coronary intervention (PCI)., Methods: We analyzed the baseline clinical and angiographic characteristics and outcomes of 155 CTO PCIs that utilized the BASE technique at 31 US and non-US centers between 2016 and 2023., Results: The BASE technique was used in 155 (7.9%) of 1968 antegrade dissection and re-entry (ADR) cases performed during the study period. The mean age was 66 ± 10 years, 88.9% of the patients were men, and the prevalence of diabetes (44.6%), hypertension (90.5%), and dyslipidemia (88.7%) was high. Compared with 1813 ADR cases that did not use BASE, the target vessel of the BASE cases was more commonly the RCA and less commonly the LAD. Lesions requiring BASE had longer occlusion length (42 ± 23 vs. 37 ± 23 mm, p = 0.011), higher Japanese CTO (J-CTO) (3.4 ± 1.0 vs. 3.0 ± 1.1, p < 0.001) and PROGRESS-CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention chronic total occlusion) (1.8 ± 1.0 vs. 1.5 ± 1.0, p = 0.008) scores, and were more likely to have proximal cap ambiguity, side branch at the proximal cap, blunt/no stump, moderate to severe calcification, and proximal tortuosity. Technical (71.6% vs. 75.5%, p = 0.334) and procedural success (71.6% vs. 72.8%, p = 0.821), as well as major adverse cardiac events (MACE) (1.3% vs. 4.1%, p = 0.124), were similar in ADR cases that used BASE and those that did not., Conclusions: The BASE technique is used in CTOs with longer occlusion length, higher J-CTO score, and more complex angiographic characteristics, and is associated with moderate success but also low MACE., (© 2023 Wiley Periodicals LLC.)

Estimating the likelihood of urgent mechanical circulatory support (MCS) can facilitate procedural planning and clinical decision-making in chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We analyzed 2,784 CTO PCIs performed between 2012 and 2021 at 12 centers. The variable importance was estimated by a bootstrap applying a random forest algorithm to a propensity-matched sample (a ratio of 1:5 matching cases with controls on center). The identified variables were used to predict the risk of urgent MCS. The performance of the risk model was assessed in-sample and on 2,411 out-of-sample procedures that did not require urgent MCS. Urgent MCS was used in 62 (2.2%) of cases. Patients who required urgent MCS were older (70 [63 to 77] vs 66 [58 to 73] years, p = 0.003) compared with those who did not require urgent MCS. Technical (68% vs 87%, p <0.001) and procedural success (40% vs 85%, p <0.001) was lower in the urgent MCS group compared with cases that did not require urgent MCS. The risk model for urgent MCS use included retrograde crossing strategy, left ventricular ejection fraction, and lesion length. The resulting model demonstrated good calibration and discriminatory capacity with the area under the curve (95% confidence interval) of 0.79 (0.73 to 0.86) and specificity and sensitivity of 86% and 52%, respectively. In the out-of-sample set, the specificity of the model was 87%. The Prospective Global Registry for the Study of Chronic Total Occlusion Intervention CTO MCS score can help estimate the risk of urgent MCS use during CTO PCI., Competing Interests: Declaration of Competing Interest Dr. Alaswad: consultant and speaker for Boston Scientific, Abbott Cardiovascular, Teleflex, and CSI Dr. Jaffer: sponsored research from Canon U.S.A., Siemens, Shockwave, Teleflex; Institutional grants: Abbott vascular, Boston Scientific, CSI, Philips, Asahi Intecc, and Biotronik; Consultant for Boston Scientific, Siemens, Biotronik, Magenta Medical, IMDS, and Asahi Intecc; Equity interest, Intravascular Imaging Inc.; DurVena; Massachusetts General Hospital has a patent licensing arrangement with Terumo, Canon U.S.A., and Spectrawave; FAJ has the right to receive royalties. Dr. Poommipanit: Asahi Intecc, Inc., Abbott, Vascular-Consultant. Dr. Khatri: received honoraria from Asahi Intecc; and is a speaker and proctor for Abbott Vascular. Dr. Patel: member of the Speakers Bureau for AstraZeneca. Dr. Yeh: grants and personal fees from Abbott Vascular, AstraZeneca, Medtronic, and Boston Scientific. Dr. ElGuindy: received consultancy and proctorship fees from Medtronic, Asahi Intecc, Boston Scientific, and Terumo. Dr. Abi-Rafeh: proctor and speaker honoraria from Boston Scientific and Abbott Vascular. Dr. Brilakis: 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, and Teleflex; research support: Boston Scientific, GE Healthcare; owner, Hippocrates LLC; shareholder: MHI Ventures, Cleerly Health, Stallion Medical. All other authors: Nothing to disclose., (Copyright © 2023 Elsevier Inc. All rights reserved.)

The left anterior descending artery (LAD) subtends a large myocardial territory. The outcomes of LAD chronic total occlusion (CTO) percutaneous coronary intervention (PCI) have received limited study. We performed a retrospective analysis of all patients who underwent LAD CTO PCI at a high-volume single center. Outcomes included in-hospital and long-term major adverse cardiovascular events (MACEs) and changes in left ventricular ejection fraction (LVEF). We performed a subgroup analysis of patients with ischemic cardiomyopathy, defined as an LVEF of 40% or less. From December 2014 to February 2021, 237 patients underwent LAD CTO PCI. The technical success rate was 97.4%, and the in-hospital MACE rate was 5.4%, A landmark analysis after hospital discharge showed an overall survival of 92% and 85% MACE-free survival at 2 years. There was no difference in overall survival or MACE-free survival between those who had ischemic cardiomyopathy versus those who did not. In patients with ischemic cardiomyopathy, LAD CTO PCI was associated with significant improvement in LVEF (10.9% at 9 months), which was further pronounced when these patients had a proximal LAD CTO and were on optimal medical therapy (14% at 6 months). In a single high-volume center, LAD CTO PCI was associated with 92% overall survival at 2 years, with no difference in survival between patients with or without ischemic cardiomyopathy. LAD CTO PCI was associated with an absolute 10% increase in LVEF at 9 months in patients with ischemic cardiomyopathy., Competing Interests: Disclosures Dr. Alaswad reports as consulting/speaker honoraria from Boston Scientific, Cardiovascular Systems Inc, LivaNova, Teleflex. Dr. Basir reports as consulting/speaker Abbott Vascular, Abiomed, Cardiovascular Systems, Chiesi, Procyrion, Zoll. Dr. Brilakis reports as consulting/speaker honoraria from Abbott Vascular, American Heart Association (associate editor Circulation), Amgen, Biotronik, Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), ControlRad, CSI, Ebix, Elsevier, GE Healthcare, InfraRedx, Medtronic, Siemens, and Teleflex; research support from Regeneron and Siemens. Shareholder: MHI Ventures. Dr. Neupane reports as consultant/speaker Boston Scientific, Teleflex, Asahi, Abiomed, CSI, Medtronic, Philips, Shockwave. Dr. Kunkel reports as speaking and consulting fees from Abiomed, CSI, and Shockwave. The remaining authors have no conflicts of interest to declare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: There are limited data describing gender differences in patients undergoing chronic total occlusion (CTO) percutaneous coronary interventions (PCI)., Methods: We compared baseline clinical and angiographic characteristics and procedural outcomes between men and women among 9457 CTO PCIs performed at 38 centers between 2012 and 2022., Results: A total of 7687 (81%) men and 1770 (19%) women were treated. Women were older, more likely to have comorbidities such as diabetes, hypertension and peripheral arterial disease, and had higher left ventricular ejection fraction. The most common CTO target vessel was the right coronary artery for both men (53%) and women (52%), although the left anterior descending artery was more frequently the target vessel among women (31% vs. 25%; p < 0.001). The J-CTO score (2.4 ± 1.3 vs. 2.2 ± 1.2; p < 0.001) as well as the PROGRESS-CTO score (1.3 ± 1.0 vs. 1.1 ± 1.0; p < 0.001) were higher among men. In female patients, antegrade wiring was more frequently the initial crossing strategy (87.6% vs. 82.4%; p < 0.001) and was more successful in crossing the target lesion (62.7% vs. 54.0%; p < 0.001) compared with men. Interventions in men required longer procedure time and fluoroscopy time, as well as higher air kerma radiation dose and contrast volume when compared to women. Technical (89% vs. 86%; p < 0.001) and procedural (87% vs. 84%; p = 0.003) success rates were higher among women. In-hospital major adverse cardiovascular events (MACE) were also higher in women (2.9% vs. 1.8%; p < 0.001)., Conclusions: Women undergoing CTO PCI had higher technical and procedural success rates, but also higher in-hospital MACE compared with men., (© 2022 Wiley Periodicals LLC.)

Objective: To compare the clinical outcomes after extraplaque (EP) versus intraplaque (IP) tracking in chronic total occlusion (CTO) percutaneous coronary intervention (PCI)., Background: The impact of modern dissection and reentry (DR) techniques on the long-term outcomes of CTO PCI remains controversial., Methods: We performed a systematic review and meta-analysis of studies that compared EP versus IP tracking in CTO PCI. Odds ratios (ORs) with 95% confidence intervals (CIs) are calculated using the Der-Simonian and Laird random-effects method., Results: Our meta-analysis included seven observational studies with 2982 patients. Patients who underwent EP tracking had significantly more complex CTOs with higher J-CTO score, longer lesion length, and more severe calcification and had significantly longer stented segments. During a median follow-up of 12 months (range 9-12 months), EP tracking was associated with a higher risk of major adverse cardiovascular events (MACE) (OR 1.50, 95% CI (1.10-2.06), p = 0.01) and target vessel revascularization (TVR) (OR 1.69, 95% CI (1.15-2.48), p = 0.01) compared with IP tracking. There was no difference in the incidence of all-cause death (OR 1.37, 95% CI (0.67-2.78), p = 0.39), myocardial infarction (MI) (OR 1.48, 95% CI (0.82-2.69), p = 0.20), stent thrombosis (OR 2.09, 95% CI (0.69-6.33), p = 0.19), or cardiac death (OR 1.10, 95% CI (0.39-3.15), p = 0.85) between IP and EP tracking., Conclusion: EP tracking is utilized in more complex CTOs and requires more stents. EP tracking is associated with a higher risk of MACE, driven by a higher risk of TVR at 1 year, but without an increased risk of death or MI compared with IP tracking. EP tracking is critically important for contemporary CTO PCI., (© 2022 Wiley Periodicals LLC.)

Background: There are limited contemporary data on the impact of success vs. failure on the outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI)., Methods: We conducted a systematic review and a meta-analysis of contemporary studies that compared the outcomes in patients who underwent successful vs. failed contemporary (2010 onwards) CTO PCI. We performed a sensitivity analysis limited to studies that started enrollment after the publication of the hybrid algorithm in 2012., Results: We included five studies with a total of 6,084 patients (successful CTO PCI n = 4,861, failed CTO PCI n = 1,223). During a median follow-up time of 12 months (range 6-60 months), successful CTO PCI was associated with a lower risk of major adverse cardiovascular events [OR: 0.61, 95% CI (0.41, 0.92), p = 0.02, I 2  = 63%] and all-cause death [OR: 0.57, 95% CI (0.33, 0.99), p = 0.05, I 2  = 60%]. Both groups had similar risk of myocardial infarction (MI) [OR 0.69, 95% CI (0.43, 1.10), p = 0.38, I 2  = 80%], target vessel revascularization (TVR) [OR: 0.56, 95% CI (0.25, 1.27), p = 0.17, I 2  = 80%], and stroke [OR: 0.52, 95% CI (0.14, 1.91), p = 0.33, I 2  = 0%]., Conclusion: In contemporary practice, successful CTO PCI was associated with a lower incidence of MACE driven by lower all-cause mortality compared with failed CTO PCI at a median follow-up of 1 year., (© 2021. Japanese Association of Cardiovascular Intervention and Therapeutics.)

Competing Interests: Funding Support and Author Disclosures Dr Alaswad has received consulting and speaker honoraria from Boston Scientific, Cardiovascular Systems, Abbott Vascular, and Teleflex. Dr Brilakis has received consulting and speaker honoraria from Abbott Vascular, the American Heart Association (associate editor, Circulation), Amgen, Asahi Intecc, Biotronik, Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), ControlRad, Cardiovascular Systems, Elsevier, GE Healthcare, IMDS, InfraRedx, Medicure, Medtronic, Opsens, Siemens, and Teleflex; is an owner of Hippocrates; and is a shareholder in MHI Ventures and Cleerly Health. Dr Basir is a consultant and speaker for Abbott Vascular, Abiomed, Cardiovascular Systems, Chiesi, Procyrion, and Zoll. Dr Megaly has reported that he has no relationships relevant to the contents of this paper to disclose.

Competing Interests: Funding Support and Author Disclosures Dr Alaswad has received consulting and speaker honoraria from Boston Scientific, Cardiovascular Systems, Abbott Vascular, and Teleflex. Dr Brilakis has received consulting and speaker honoraria from Abbott Vascular, American Heart Association (associate editor, Circulation), Amgen, Asahi Intecc, Biotronik, Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), ControlRad, Cardiovascular Systems, Elsevier, GE Healthcare, IMDS, InfraRedx, Medicure, Medtronic, Opsens, Siemens, and Teleflex; is an owner of Hippocrates; and is a shareholder in MHI Ventures and Cleerly Health. Dr Basir is a consultant and speaker for Abbott Vascular, Abiomed, Cardiovascular Systems, Chiesi, Procyrion, and Zoll. Dr Megaly has reported that he has no relationships relevant to the contents of this paper to disclose.

Background: We sought to examine the procedural and clinical outcomes of patients who underwent chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in the setting of acute myocardial infarction (AMI)., Methods: We assessed the clinical and procedural characteristics, technical success, procedural success, and in-hospital outcomes of 2314 patients who underwent CTO-PCI at 20 experienced centers between 2012 and 2017, classified according to whether or not they presented with AMI., Results: Mean patient age was 65 ± 10 years, 85% were men, and 154 (6.7%) presented with AMI (5.5% with non-ST segment elevation myocardial infarction, 1.1% with ST-segment elevation myocardial infarction). Compared with non-AMI patients who underwent CTO-PCI, AMI patients had higher prevalence of diabetes (56% vs 42%; P<.01) and lower median left ventricular ejection fraction (48% vs 54%; P<.001). The CTO angiographic characteristics were similar between the 2 groups. Compared with non-AMI patients undergoing CTO-PCI, AMI patients had more frequent use of antegrade wire escalation (86.0% vs 78.9%; P=.03) and more frequent use of hemodynamic support devices (16.2% vs 3.4%; P<.01), and were more likely to have a non-CTO lesion treated (34.0% vs 26.6%; P=.03). AMI and non-AMI patients had similar technical success (90% vs 87%; P=.26), procedural success (88% vs 85%; P=.38), and incidence of in-hospital MACE (2.6% vs 2.5%; P=.94)., Conclusion: CTO-PCI is performed infrequently in AMI patients and is associated with similar technical and procedural success rates and in-hospital major adverse cardiovascular event rates when compared with CTO-PCI performed in non-AMI patients.

Background: Left main coronary artery (LMCA) chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study., Methods: We reviewed 4436 CTO-PCIs performed in 4340 patients between 2012 and 2018 at 25 sites. LMCA-CTO-PCI was performed in 20 cases (0.45%). We examined the clinical and angiographic characteristics and procedural outcomes of these cases., Results: Mean patient age was 68 ± 11 years and 65% were men. Most patients (85%) had undergone prior coronary artery bypass graft surgery and had a protected left main. Mean J-CTO score was 2.7 ± 1.3, mean PROGRESS-CTO score was 1.3 ± 1.1, and mean PROGRESS-CTO Complications score was 3.8 ± 1.9. Antegrade-wire escalation was the most common successful crossing strategy (50%), followed by retrograde crossing (30%) and antegrade dissection/re-entry (10%). Technical and procedural success rates were both 85%. One patient with failed LMCA-CTO-PCI had periprocedural myocardial infarction. Median procedure time was 178 minutes (interquartile range [IQR], 123-250 minutes), median contrast volume was 190 mL (IQR, 133-339 mL), and patient air kerma radiation dose was 2.6 Gray (IQR, 1.3-3.9 Gray)., Conclusions: LMCA-CTO-PCI is infrequent, is performed mostly in patients with prior coronary artery bypass graft surgery, and is associated with good procedural outcomes.

Objective: To study outcomes with use of percutaneous mechanical circulatory support (MCS) devices in chronic total occlusion (CTO) percutaneous coronary intervention (PCI)., Methods: We examined characteristics and outcomes of 1598 CTO-PCIs performed from 2012-2017 at 12 high-volume centers., Results: Patient age was 66 ± 10 years; 86% were men. An MCS device was used electively in 69 procedures (4%) and urgently in 22 procedures (1%). The most commonly used elective MCS device was Impella 2.5 or CP (62%). Compared to patients without elective MCS, patients with elective MCS had higher prevalence of prior heart failure (55% vs 29%; P<.001), prior coronary artery bypass graft surgery (49% vs 35%; P=.02), and lower left ventricular ejection fraction (34 ± 14% vs 50 ± 14%; P<.001). MCS patients had a higher prevalence of moderate/ severe calcification (88% vs 55%; P<.001) and higher J-CTO scores (3.1 ± 1.2 vs 2.6 ± 1.2; P<.01), and a greater proportion underwent retrograde crossing attempts (55% vs 39%; P<.01). Despite more complex characteristics in MCS patients, technical success rates (88% vs 87%; P=.70) and procedural success rates (83% vs 87%; P=.32) were similar in the two groups. Use of elective MCS was associated with longer procedure and fluoroscopy times, and higher incidences of in-hospital major adverse cardiovascular events (8.7% vs 2.5%; P<.01) and bleeding (7.3% vs 1.0%; P<.001)., Conclusion: Elective MCS was used in 4% of patients undergoing CTO-PCI. Despite more complex clinical and angiographic characteristics, elective use of MCS in high-risk patients is associated with similar technical and procedural success rates, but higher risk of complications, compared to cases without elective MCS.

Objectives: To evaluate the success rates and outcome of the hybrid algorithm for chronic total occlusion (CTO) percutaneous coronary intervention (PCI) by a single operator in two different clinical settings., Methods: We compared 279 consecutive CTO PCIs performed by a single, high-volume operator using the hybrid algorithm in two different clinical settings. Data were collected through the PROGRESS CTO Registry. We compared 145 interventions performed in a community program (cohort A) with 134 interventions performed in a referral center (cohort B)., Results: Patient in cohort B had more complex lesions with higher J-CTO (3.0 vs. 3.41; p<0.001) and Progress CTO (1.5 vs.1.8, P=0.003) scores, more moderate to severe tortuosity (38% vs. 64%; p<0.001), longer total occlusion length (25 vs. 40mm; p<0.001) and higher prevalence of prior failed CTO PCI attempts (15% vs. 35%; p=0.001). Both technical (95% vs. 91%; p=0.266) and procedural (94% vs. 88%; p=0.088) success rates were similar between the two cohorts despite significantly different lesion complexity. Overall major adverse cardiovascular events were higher in cohort B (1.4% vs. 7.8%; p=0.012) without any significant difference in mortality (0.7% vs. 2.3%, p=0.351)., Conclusions: In spite of higher lesion complexity in the setting of a quaternary-care referral center, use of the hybrid algorithm for CTO PCI enabled similarly high technical and procedural success rates as compared with those previously achieved by the same operator in a community-based program at the expense of a higher rate of MACE., (Copyright © 2017 Elsevier Inc. All rights reserved.)