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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.)

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 use of mechanical circulatory support (MCS) in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study. We analyzed the clinical and angiographic characteristics, and procedural outcomes of 7,171 CTO PCIs performed between 2012 and 2021 at 35 international centers. Mean age was 64.5 ± 10 years, mean left ventricular ejection fraction was 50 ± 13%. MCS was used in 4.5%, prophylactically in 78.7%, and urgently in 21.3%. The most common type of MCS overall was Impella CP (Abiomed) (55.5%), followed by intra-aortic balloon pump (14.8%) and TandemHeart (LivaNova Inc.) (10.0%). Prophylactic MCS patients were more likely to have diabetes mellitus (55% vs 42%, p <0.001) and had more complex lesions compared with cases without prophylactic MCS (Japan-CTO score: 2.80 ± 1.22 vs 2.39 ± 1.27, p <0.001). Cases with prophylactic MCS had similar technical (86% vs 87%, p = 0.643) but lower procedural (80% vs 86%, p = 0.028) success rates and higher rates of periprocedural major cardiac adverse events compared with no prophylactic MCS use (6.55% vs 1.68%, p <0.001). Urgent MCS use was associated with lower technical (68% vs 87%, p <0.001) and procedural (39% vs 86%, p <0.001) success rates and higher major cardiac adverse events compared with no-MCS use (32.26% vs 1.68%, p <0.001). The differences persisted in multivariable analyses. In summary, in this contemporary multicenter registry, MCS was used in 4.5% of CTO PCIs, mostly prophylactically (78.7%). Elective MCS cases had similar technical success but a higher risk of complications. Urgent MCS cases had lower technical and procedural success and higher periprocedural major complication rates., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: There are limited data on the limited antegrade subintimal tracking (LAST) technique for chronic total occlusion (CTO) percutaneous coronary intervention (PCI)., Objectives: The aim of this study was to analyze the frequency of use and outcomes of the LAST technique for CTO PCI., Methods: We analyzed 2,177 CTO PCIs performed using antegrade dissection and re-entry (ADR) in the PROGRESS-CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention) registry between 2012 and January 2022 at 39 centers. ADR was attempted in 1,465 cases (67.3%)., Results: Among antegrade re-entry cases, LAST was used in 163 (11.1%) (primary LAST in 127 [8.7%] and secondary LAST [LAST after other ADR approaches failed] in 36 [2.5%]), the Stingray system (Boston Scientific) in 980 (66.9%), subintimal tracking and re-entry in 387 (26.4%), and contrast-guided subintimal tracking and re-entry in 29 (2.0%). The mean patient age was 65.2 ± 10 years, and 85.8% were men. There was no significant difference in technical (71.8% vs 77.8%; P = 0.080) and procedural (69.9% vs 75.3%; P = 0.127) success and major cardiac adverse events (1.84% vs 3.53%; P = 0.254) between LAST and non-LAST cases. However, on multivariable analysis, the use of LAST was associated with lower procedural success (OR: 0.61; 95% CI: 0.41-0.91). Primary LAST was associated with higher technical (76.4% vs 55.6%; P = 0.014) and procedural (75.6% vs 50.0%; P = 0.003) success and similar major adverse cardiac event (1.57% vs 2.78%; P = 0.636) rates compared with secondary LAST., Conclusions: LAST was used in 11.1% of antegrade re-entry CTO PCI cases and was associated with lower procedural success on multivariable analysis, suggesting a limited role of LAST in contemporary CTO PCI., Competing Interests: Funding Support and Author Disclosures This work was supported by many philanthropy partners, including our anonymous donors, Drs Mary Ann and Donald A. Sens, Ms Dianne and Dr Cline Hickok, Ms Charlotte and Mr Jerry Golinvaux Family Fund, the Roehl Family Foundation, and the Joseph Durda Foundation, and Ms Wilma and Mr Dale Johnson. Dr Alaswad is a consultant and speaker for Boston Scientific, Abbott Cardiovascular, Teleflex, and Cardiovascular Systems, Inc. Dr Karmpaliotis has received honoraria from Abbott Vascular and Boston Scientific; and has equity in Saranas, Soundbite, and Traverse Vascular. Dr Kirtane is a consultant for Interventional Medical Device Solutions; and has received travel expenses/meals from Medtronic, Boston Scientific, Abbott Vascular, Abiomed, Cardiovascular Systems, Inc, Siemens, Philips, ReCor Medical, Chiesi, OpSens, Zoll, and Regeneron. Dr Jaffer has received sponsored research support from Canon, Siemens, Teleflex, Shockwave, Amarin, Mercator, Boston Scientific, and HeartFlow; is a consultant/speaker for Boston Scientific, Biotronik, Siemens, Magenta Medical, Interventional Medical Device Solutions, and Philips; and holds equity in Intravascular Imaging, Inc and DurVena, Inc. Massachusetts General Hospital has a patent licensing arrangement with Terumo, Canon, and Spectrawave. Dr Kandzari has received institutional research/grant support from Abbott Vascular, Biotronik, Boston Scientific, Cardiovascular Systems, Inc, Medtronic, Orbus Neich, and Teleflex; and has received personal consulting honoraria from Biotronik, Cardiovascular Systems, Inc, and Medtronic. Dr Poommipanit is a consultant for Asahi Intecc, Abbott, and Vascular-Consultant. Dr Khatri received honoraria from Asahi Intecc; and is a speaker and proctor for Abbott Vascular. Dr ElGuindy has received consultancy and proctorship fees from Medtronic, Asahi Intecc, Boston Scientific, and Terumo. Dr Abi Rafeh is a speaker for Boston scientific and Shockwave Medical. Dr Burke is a shareholder in Egg Medical and MHI Ventures. 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), Cardiovascular Systems, Inc, Elsevier, GE Healthcare, Interventional Medical Device Solutions, Medicure, Medtronic, Siemens, and Teleflex; provides research support for 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 © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: The retrograde approach to coronary chronic total occlusions (CTOs) can be used as the initial crossing strategy (primary retrograde) or after failure of antegrade crossing attempts (secondary retrograde)., Methods: We compared baseline clinical and angiographic characteristics and procedural outcomes of primary vs secondary retrograde crossing for CTO percutaneous coronary intervention (PCI) among 2789 procedures performed at 34 centers between 2012 and 2021., Results: Retrograde CTO-PCI was performed as the primary crossing strategy in 1086 cases (38.9%) and as a secondary approach in 1703 cases (61.1%). Patients in the primary group had slightly lower left ventricular ejection fraction (49.1% vs 50.4%; P=.02), were more likely to have had prior coronary artery bypass graft surgery (52.9% vs 38.4%; P&lt;.001), and had higher J-CTO (3.31 ± 0.98 vs 2.99 ± 1.09; P&lt;.001) and PROGRESS-CTO scores (1.47 ± 0.92 vs 1.29 ± 0.99; P&lt;.001). Technical (81.4% vs 77.3%; P=.01) and procedural success rates (78.6% vs 74.1%; P&lt;.01) were higher in the primary retrograde group, with no difference between in-hospital major adverse event rates (4.3% vs 4.0%; P=.66). Contrast volume (250 mL [interquartile range (IQR), 176-347] vs 270 mL [IQR, 190-367]; P&lt;.001) and procedure time (175 minutes [IQR, 127-233] vs 180 minutes [IQR, 142-236]; P&lt;.001) were lower in the primary group., Conclusions: Use of retrograde approach as the primary crossing strategy is associated with higher rates of technical and procedural success and similar rates of in-hospital major adverse cardiac events compared with secondary retrograde CTO-PCI.

Objectives: We sought to assess in-hospital and long-term outcomes of retrograde compared with antegrade-only percutaneous coronary intervention for chronic total occlusion (CTO PCI)., Background: Procedural and clinical outcomes following retrograde compared with antegrade-only CTO PCI remain unknown., Methods: Using the core-lab adjudicated OPEN-CTO registry, we compared the outcomes of retrograde to antegrade-only CTO PCI. Primary endpoints included were in-hospital major adverse cardiac and cerebrovascular events (MACCE) (all-cause death, stroke, myocardial infarction [MI], emergency cardiac surgery, or clinically significant perforation) and MACCE at 1-year (all-cause death, MI, stroke, target lesion revascularization, or target vessel reocclusion)., Results: Among 885 single CTO procedures from the OPEN-CTO registry, 454 were retrograde and 431 were antegrade-only. Lesion complexity was higher (J-CTO score: 2.7 vs. 1.9; p < .001) and technical success lower (82.4 vs. 94.2%; p < .001) in retrograde compared with antegrade-only procedures. All-cause death was higher in the retrograde group in-hospital (2 vs. 0%; p = .003), but not at 1-year (4.9 vs. 3.3%; p = .29). Compared with antegrade-only procedures, in-hospital MACCE rates (composite of all-cause death, stroke, MI, emergency cardiac surgery, and clinically significant perforation) were higher in the retrograde group (10.8 vs. 3.3%; p < .001) and at 1-year (19.5 vs. 13.9%; p = .03). In sensitivity analyses landmarked at discharge, there was no difference in MACCE rates at 1 year following retrograde versus antegrade-only CTO PCI. Improvements in Seattle Angina Questionnaire Quality of Life scores at 1-year were similar between the retrograde and antegrade-only groups (29.9 vs 30.4; p = .58)., Conclusions: In the OPEN-CTO registry, retrograde CTO procedures were associated with higher rates of in-hospital MACCE compared with antegrade-only; however, post-discharge outcomes, including quality of life improvements, were similar between technical modalities., (© 2020 Wiley Periodicals LLC.)

Coronary perforation is a potential complication of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We analyzed 2,097 CTO PCIs performed in 2,049 patients from 2012 to 2017. Patient age was 65 ± 10 years, 85% were men, and 36% had prior coronary artery bypass graft surgery. Technical and procedural success were 88% and 87%, respectively. A major periprocedural adverse cardiovascular event occurred in 2.6%. Coronary perforation occurred in 85 patients (4.1%); The frequency of Ellis class 1, 2, and 3 perforations was 21%, 26%, and 52%, respectively. Perforation occurred more frequently in older patients and those with previous coronary artery bypass graft surgery (61% vs 35%, p < 0.001). Cases with perforation were angiographically more complex (Multicenter CTO Registry in Japan score 3.0 ± 1.2 vs 2.5 ± 1.3, p < 0.001). Twelve patients (14%) with perforation experienced tamponade requiring pericardiocentesis. Patient age, previous PCI, right coronary artery target CTO, blunt or no stump, use of antegrade dissection re-entry, and the retrograde approach were associated with perforation. Adjusted odds ratio for periprocedural major periprocedural adverse cardiovascular events among patients with perforation was 15.04 (95% confidence interval 7.35 to 30.18). In conclusion, perforation occurs relatively infrequently in contemporary CTO PCI performed by experienced operators and is associated with baseline patient characteristics and angiographic complexity necessitating use of advanced crossing techniques. In most cases, perforations do not result in tamponade requiring pericardiocentesis, but they are associated with reduced technical and procedural success, higher periprocedural major adverse events, and reduced procedural efficiency., (Published by Elsevier Inc.)

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/m 2 vs 29 ± 6 kg/m 2 ; 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., (© 2016 Diabetes UK.)