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Background: Contemporary chronic total occlusion (CTO) percutaneous coronary intervention (PCI) practice has received limited study., Aim: To examine the contemporary CTO PCI practice., Methods: We performed an online, anonymous, international survey of CTO PCI operators., Results: Five hundred forty-five CTO PCI operators and 190 interventional cardiology fellows with an interest in CTO PCI participated in this survey. Almost half were from the United States (41%), most (93%) were men, and the median h/week spent in the hospital was 58. Median annual case numbers were 205 (150-328) for PCIs and 20 (5-50) for CTO PCIs. Almost one-fifth (17%) entered CTO cases into registries, such as PROGRESS-CTO (55%) and EuroCTO (20%). More than one-third worked at academic institutions (39%), 31% trained dedicated CTO fellows, and 22% proctored CTO PCI. One-third (34%) had dedicated CTO PCI days. Most (51%) never discharged CTO patients the same day, while 17% discharged CTO patients the same day >50% of the time. After successful guidewire crossing, 38% used intravascular imaging >90% of the time. Most used CTO scores including J-CTO (81%), PROGRESS-CTO (35%), and PROGRESS-CTO complications scores (30%). Coronary artery perforation was encountered within the last month by 19%. On a scale of 0-10, the median comfort levels in treating coronary artery perforation were: covered stents 8.8 (7.0-10), coil embolization 5.0 (2.1-8.5), and fat embolization 3.7 (0.6-7.3). Most (51%) participants had a complication cart/kit and 25% conducted regular complication drills with catheterization laboratory staff., Conclusion: Contemporary CTO PCI practices vary widely. Further research on barriers to following the guiding principles of CTO PCI may improve patient outcomes., (© 2023 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: 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.)

Background: The impact of preprocedural anemia on the outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study., Methods: We examined the clinical and angiographic characteristics and procedural outcomes of 8633 CTO PCIs performed at 39 US and non-US centers between 2012 and 2023. Anemia was defined as a hemoglobin level of <13 g/dL in men and <12 g/dL in women., Results: Anemia was present in 1652 (19%) patients undergoing CTO PCI. Anemic patients had a higher incidence of comorbidities, such as diabetes mellitus, hypertension, dyslipidemia, heart failure, cerebrovascular disease, and peripheral arterial disease. CTOs in anemic patients were more likely to have complex angiographic characteristics, including smaller diameter, longer length, moderate to severe calcification, and moderate to severe proximal tortuosity. Anemic patients required longer procedure (119 vs. 107 min; p < 0.001) and fluoroscopy (45 vs. 40 min; p < 0.001) times but received similar contrast volumes. Technical success was similar between the two groups. In-hospital major adverse cardiac events (MACE) rates were higher in patients with anemia; however, this association was no longer significant after adjusting for confounding factors. Baseline anemia was independently associated with follow-up MACE (adjusted hazard ratio [HR]: 1.63; 95% confidence interval [CI]: 1.07-2.49; p = 0.023) and all-cause mortality (adjusted HR: 3.03; 95% CI: 1.41-6.49; p = 0.004)., Conclusions: Preprocedural anemia is associated with more comorbidities, higher lesion complexity, longer procedure times, and higher follow-up MACE and mortality after CTO PCI., (© 2023 Wiley Periodicals LLC.)

Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has been rapidly evolving in different parts of the world. We examined the clinical and angiographic characteristics and procedural outcomes of 1,079 consecutive CTO PCIs performed in 1,063 patients at 10 centers in the Middle East, North Africa, Turkey, and Asia regions between 2018 and 2022. The mean age was 61 ± 10 years and 82% of the patients were men. The prevalence of diabetes (49%) and previous PCI (50%) was high. The most common target vessel was the right coronary artery (51%), followed by the left anterior descending artery (33%) and the circumflex artery (15%). The mean Japanese CTO score was 2.1 ± 1.2 and mean PROGRESS-CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention) score was 1.2 ± 1.0. The technical and procedural success rates were high (91% and 90%, respectively) with a low incidence (1.6%) of in-hospital major adverse cardiac events. The incidence of perforation was 4.6% (n = 50): guidewire exit was the most common mechanism of perforation (48%) and 14 patients required pericardiocentesis (28%). Antegrade wire escalation was the most common crossing strategy used (91%), followed by retrograde approach (24%) and antegrade dissection and re-entry (12%). Median contrast volume, air kerma radiation dose, and fluoroscopy time were 300 (200 to 400) ml, 3.7 (2.0 to 6.3) Gy, and 40 (25 to 65) minutes, respectively. In conclusion, high success and acceptable complication rates are currently achieved at experienced centers in the Middle East, North Africa, Turkey, and Asia regions using a combination of crossing strategies., Competing Interests: Declaration of Competing Interest Dr. ElGuindy receives consulting honoraria from Medtronic, Boston Scientific, Asahi Intecc, Terumo; proctorship fees from Medtronic, Boston Scientific, Asahi Intecc, Terumo. Dr. Rafeh receives proctor and speaker honoraria from Boston Scientific and Shockwave medical. Dr. Sandoval previously served on the Advisory Boards for Roche Diagnostics and Abbott Diagnostics without personal compensation and has also been a speaker without personal financial compensation for Abbott Diagnostics. Dr. Burke is a shareholder in MHIC, Egg Medical. Dr. Brilakis receives consulting/speaker honoraria from Abbott Vascular, American Heart Association (associate editor 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; receives research support from Boston Scientific, GE Healthcare; is an owner of Hippocrates LLC; is a shareholder in MHI Ventures, Cleerly Health, Stallion Medical. The remaining authors have no competing interests to declare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

The outcomes of chronic total occlusion (CTO) percutaneous coronary interventions (PCIs) in patients with previous coronary artery bypass graft (CABG) surgery have received limited study. We examined the baseline characteristics and outcomes of CTO PCIs performed at 47 United States and non-United States centers between 2012 and 2023. Of the 12,164 patients who underwent CTO PCI during the study period, 3,475 (29%) had previous CABG. Previous CABG patients were older, more likely to be men, and had more comorbidities and lower left ventricular ejection fraction and estimated glomerular filtration rate. Their CTOs were more likely to have moderate/severe calcification and proximal tortuosity, proximal cap ambiguity, longer lesion length, and higher Japanese CTO scores. The first and final successful crossing strategy was more likely to be retrograde. Previous CABG patients had lower technical (82.1% vs 88.2%, p <0.001) and procedural (80.8% vs 86.8%, p <0.001) success, higher in-hospital mortality (0.8% vs 0.3%, p <0.001), acute myocardial infarction (0.9% vs 0.5%, p = 0.007) and perforation (7.0% vs 4.2%, p <0.001) but lower incidence of pericardial tamponade and pericardiocentesis (0.1% vs 1.3%, p <0.001). At 2-year follow-up, the incidence of major adverse cardiac events, repeat PCI and acute coronary syndrome was significantly higher in previous CABG patients, whereas all-cause mortality was similar. In conclusion, patients with previous CABG who underwent CTO PCI had more complex clinical and angiographic characteristics and lower success rate, higher perioperative mortality, and myocardial infarction but lower tamponade, and higher incidence of major adverse cardiac events with similar all-cause mortality during follow-up., Competing Interests: Declaration of Competing Interest Dr. Choi reports as Medtronic advisory board. Dr. Poommipanit reports as consultant for Asahi Intecc, and Abbott Vascular. Dr. Alaswad reports as consultant and speaker for Boston Scientific, Abbott Cardiovascular, Teleflex, and Cardiovascular Systems Inc. Dr. Rinfret reports as consultant for Boston Scientific, Teleflex, Medtronic, Abbott, and Abiomed. Dr. Basir reports as consultant for Abbott Vascular, Abiomed, Cardiovascular Systems, Inc, Chiesi, and Zoll. Dr. Khatri has received personal honoraria for proctoring and speaking fees from Abbott Vascular, Medtronic, Terumo, Shockwave, and Boston Scientific. Dr. Karmpaliotis has received honoraria from Boston Scientific and Abbott Vascular and has equity in Saranas, SoundBite Medical, and Traverse Vascular. Dr. Nicholson has been a proctor for and on the speaker's bureau and advisory boards for Abbott Vascular, Boston Scientific, and Asahi Intecc; and he reports intellectual property with Vascular Solutions. Dr. Davies reports as speaking honoraria from Abiomed, Asahi Intec, Boston Scientific, Medtronic, Teleflex, and Shockwave Medical. She also serves on advisory boards for Abiomed, Avinger, Boston Scientific, Medtronic, and Rampart. Dr. Jaffer has done sponsored research for Canon, Siemens, Shockwave, Teleflex, Mercator, and Boston Scientific; and has been a consultant for Boston Scientific, Siemens, Magenta Medical, IMDS, Asahi Intecc, Biotronik, Philips, and Intravascular Imaging Inc. He has equity interest in Intravascular Imaging Inc, DurVena; and the right to receive royalties through Massachusetts General Hospital licensing arrangements with Terumo, Canon, and Spectrawave. Dr. Azzalini received consulting fees from Teleflex, Abiomed, GE Healthcare (Little Chalfont, United Kingdom), Asahi Intecc, Philips, Abbott Vascular, Reflow Medical, and Cardiovascular Systems, Inc. Dr. ElGuindy reports as consulting honoraria: Medtronic, Boston Scientific, Asahi Intecc, Terumo; Proctorship fees: Medtronic, Boston Scientific, Asahi Intecc, Terumo. Dr. Abi‐Rafeh: Proctor and speaker honoraria from Boston Scientific and Shockwave Medical. Dr. Allana: consulting for Boston Scientific Corporation and Abiomed. Dr. Sandoval: previously served on the Advisory Boards for Roche Diagnostics and Abbott Diagnostics without personal compensation; and has also been a speaker without personal financial compensation for Abbott Diagnostics. Dr. Burke: consulting and speaker honoraria from Abbott Vascular and Boston Scientific. 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, Teleflex, and Terumo; research support: Boston Scientific, GE Healthcare; owner, Hippocrates LLC; shareholder: MHI Ventures, Cleerly Health, Stallion Medical. Dr. Kearney: consultant fee/honoraria/speaker's bureau (personal): Boston Scientific Corporation; Abiomed; Cardiovascular Systems, Inc; grant support/research contract (personal) Teleflex. The remaining authors have no competing interests to declare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

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.)

Background: Aortocoronary dissection is a potentially serious complication of chronic total occlusion (CTO) percutaneous coronary intervention (PCI)., Methods: We examined the incidence, mechanisms, treatment, and outcomes of aortocoronary dissection among 12,117 CTO PCIs performed between 2012 and 2022 in a large multicenter CTO PCI registry., Results: The incidence of aortocoronary dissection was 0.2% (n = 27). Most aortocoronary dissections occurred in the right coronary artery (96.3%, n = 26). The baseline clinical characteristics of patients with and without aortocoronary dissection were similar, except for dyslipidemia, which was less common in patients with aortocoronary dissection (70.4% vs. 86.0%; p = 0.019). The retrograde approach was used more commonly among cases complicated by aortocoronary dissection (59.3% vs. 31.0%; p = 0.002). Technical (74.1% vs. 86.6%; p = 0.049) and procedural (70.4% vs. 85.2%; p = 0.031) success rates were lower among aortocoronary dissection cases, with a similar incidence of in-hospital major adverse cardiovascular events (3.7% vs. 2.0%; p = 0.541). Of the 27 patients with aortocoronary dissection, 19 (70.4%) were treated with ostial stenting and 8 (29.6%) were treated conservatively without subsequent adverse clinical outcomes. No patients required emergency surgery. Follow-up was available for 22 patients (81.5%): during a mean follow up of 767 (±562) days, the incidence of in-stent restenosis was 11.1% (n = 3)., Conclusions: Aortocoronary dissection occurred in 0.2% of CTO PCIs performed by experienced operators, was associated with lower technical and procedural success, and was treated most commonly with ostial stenting. None of the patients required emergency cardiac surgery., (© 2023 Wiley Periodicals LLC.)

Background: Although discouraged, ad hoc chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is occasionally performed., Methods: We examined the clinical, angiographic characteristics, and procedural outcomes of patients who underwent ad hoc CTO PCI in the Prospective Global Registry for the Study of CTO Intervention (PROGRESS-CTO, NCT02061436)., Results: Of the 10,998 patients included in the registry, 899 (8.2%) underwent ad hoc CTO PCI. The incidence of ad hoc CTO PCI decreased from 18% in 2016 to 3% in 2022. Ad hoc CTO PCI patients had a lower prevalence of comorbidities and less complex angiographic characteristics demonstrated by lower J-CTO score (1.9±1.2 vs 2.4±1.3, P < .001). In these patients, PROGRESS-CTO major adverse cardiovascular events (MACE) (1.9±1.4 vs 2.5±1.7), mortality (1.2±1.0 vs 1.6±1.1), and perforation (1.5±1.2±2.2 vs 1.5) scores were lower (P < .001). Technical success was similar between the groups (86%). MACE were lower in the ad hoc CTO PCI group (.8% vs 2.0%, P=.009). Ad hoc CTO PCI was not associated with MACE after adjusting for potential confounders, odds ratio: .69 (95% confidence interval, .30-1.57). In patients with higher J-CTO scores, planned CTO PCI was associated with higher technical success (P < .001)., Conclusion: Approximately 8% of CTO PCI procedures are performed ad hoc, usually in less complex lesions and patients with lower complication risk. While ad hoc CTO PCI might be appropriate for carefully selected cases, a staged approach is recommended for most CTO PCI.

Chronic total occlusion (CTO) percutaneous coronary interventions (PCIs) can be lengthy procedures. We sought to investigate the effect of procedural time on CTO PCI outcomes. We examined the procedural time required for the various steps of CTO PCI in 6,442 CTO PCIs at 40 US and non-US centers between 2012 and 2022. The mean and median procedure times were 129 ± 76 and 112 minutes, respectively, with no significant change over time. The median times from access to wire insertion, guidewire manipulation time, and post crossing were 20, 32, and 53 minutes, respectively. Lesions crossed in <30 minutes were less complex, as reflected by lower Japanese CTO score (1.89 ± 1.19, p <0.001) than lesions that were not successfully crossed (2.88 ± 1.22) and lesions that were crossed in ≥30 minutes (2.85 ± 1.13). The likelihood of successful crossing if crossing was not achieved after 30, 90, and 180 minutes were a 76.7%, 60.7%, and 42.7%, respectively. The parameters independently associated with ≥30 minutes guidewire manipulation time in patients with a primary antegrade approach included left anterior descending target vessel, proximal cap ambiguity, blunt/no stump, occlusion length, previous failed attempt, medium/severe calcification, and medium/severe tortuosity. The mean duration of CTO PCI is approximately 2 hours (∼20% of time for access to wire insertion, ∼30% wire manipulation time, and ∼50% postwiring time). Guidewire crossing time was shorter in less complex lesions and in cases without complications., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Death is a rare but devastating complication of chronic total occlusion (CTO) percutaneous coronary intervention., Methods: We examined the clinical characteristics and procedural outcomes of patients who died periprocedurally in the Prospective Global Registry for the Study of CTO Interventions (PROGRESS-CTO)., Results: Of the 12 928 patients who underwent CTO percutaneous coronary intervention between 2012 and 2022, 52 (0.4%) died during the index hospitalization. Patients who died were more likely to have a history of heart failure (43% versus 28%; P =0.023). The J-CTO ([Multicenter CTO Registry of Japan]; 2.8±1.1 versus 2.4±1.3; P =0.019), PROGRESS-CTO mortality (2.6±0.9 versus 1.6±1.1; P <0.001), and PROGRESS-CTO pericardiocentesis (2.9±1.1 versus 1.9±1.3; P <0.001) scores were higher in patients who died. In these patients, the use of left ventricular assist devices was also higher (41% versus 3.5%; P <0.001), and retrograde crossing was more often the first crossing strategy (33% versus 13%; P <0.001). The cause of death was cardiac in 43 patients (83%) and noncardiac in 9 patients (17%). Complications leading to cardiac death were: tamponade in 30 patients (58%), acute myocardial infarction in 9 (17.3%), and cardiac arrest/shock in 4 (7.7%). Noncardiac causes of death were: stroke in 3 (5.8%), renal failure in 2 (3.8%), respiratory distress in 2 (3.8%), and hemorrhagic shock in 2 (3.8%)., Conclusions: Approximately 0.4% of patients who underwent CTO percutaneous coronary intervention died during the index hospitalization. The main cause of death was tamponade in 58%. PROGRESS-CTO complication scores might help in risk stratification and procedural planning in patients undergoing CTO percutaneous coronary intervention., Registration: URL: https://www., Clinicaltrials: gov; Unique Identifier: NCT02061436., Competing Interests: Disclosures Dr Alaswad is a consultant and speaker for Boston Scientific, Abbott Cardiovascular, Teleflex, and CSI. Dr Jaffer performed sponsored research: Canon, Siemens, Shockwave, Teleflex, Mercator, Boston Scientific; Consultant: Boston Scientific, Siemens, Magenta Medical, IMDS, Asahi Intecc, Biotronik, Philips, Intravascular Imaging. Equity interest—Intravascular Imaging, Inc, DurVena. Massachusetts General Hospital—licensing arrangements: Terumo, Canon, Spectrawave, for which FAJ has right to receive royalties. Dr Doshi participated in speaker’s bureau for Abbott Vascular, Boston Scientific, and Medtronic and research support from Biotronik. Dr Davies received honoraria/consulting from Medtronic, Seimens Healthineers and Asahi intec. Dr ElGuindy received consulting Honoraria from Medtronic, Boston Scientific, Asahi Intecc, Abbott; proctorship fees from Medtronic, Boston Scientific, Asahi Intecc, Terumo; and eEducational grants: Medtronic. Dr Patel received consulting Honoraria from Abbott, Medtronic, Terumo, Cardiovascular Systems, Inc. Dr Potluri is speaker in advisory board, proctor for Boston Scientific, medtronic, Abbott, Terumo, Shockwave. Dr Burke is Shareholder for Egg Medical and MHI Ventures. Dr Brilakis 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), ControlRad, CSI, Elsevier, GE Healthcare, IMDS, InfraRedx, Medicure, Medtronic, Opsens, Siemens, and Teleflex; research support: Boston Scientific, GE Healthcare; owner, Hippocrates LLC; shareholder: MHI Ventures, Cleerly Health, Stallion Medical. The other authors report no conflicts.

Background: The retrograde strategy is a common approach used in complex chronic total occlusion (CTO) percutaneous coronary intervention (PCI). The ERCTO Retrograde score is a tool that aims to predict the likelihood of technical success for retrograde CTO PCI procedures by evaluating 5 parameters: calcification, distal opacification, proximal tortuosity, collateral connection classification, and operator volume., Methods: We evaluated the performance of the ERCTO Retrograde score using data from 2341 patients enrolled in the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO) at 35 centers between 2013 and 2023., Results: Retrograde CTO PCI was the primary crossing strategy in 871 cases (37.2%) and a secondary crossing strategy in 1467 cases (62.8%). Technical success was achieved in 1,810 cases (77.3%). The technical success rate was higher for primary retrograde cases compared with secondary retrograde cases (79.8% vs 75.9%; P=.031). The ERCTO Retrograde score was positively associated with the likelihood of procedural success. The c-statistic of the ERCTO retrograde score was 0.636 (95% confidence intervals [CI]: .610-.662) for all cases and 0.651 (95% CI: .607-.695) for primary retrograde cases., Conclusions: The ERCTO Retrograde score has modest predictive capacity for technical success in retrograde CTO PCI.

Background: Same day discharge (SDD) following chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study., Methods: We evaluated the clinical, angiographic, and procedural characteristics of patients discharged the same day versus those kept for overnight observation in the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO, NCT02061436)., Results: Of the 7181 patients who underwent CTO PCI, 943 (13%) had SDD. The SDD rate increased from 3% in 2015 to 21% in 2022. Patients with SDD were less likely to have a history of heart failure (21% vs. 26%, p = 0.005), chronic lung disease (10% vs. 15%, p = 0.001), or anemia (12% vs. 19%, p < 0.001). Technical success (87% vs. 88%, p = 0.289) was similar, but in-hospital major adverse cardiovascular events (0.0% vs. 0.4%, p = 0.041) were lower in SDD. In multivariable logistic regression analysis, prior myocardial infarction odds ratio (OR): 0.71 (95% confidence interval [CI]: 0.59-0.87, p = 0.001), chronic lung disease OR: 0.64 (95% CI: 0.47-0.88, p = 0.006), and increasing procedure time OR: 0.93 (95% CI: 0.91-0.95, p < 0.001, per 10-min increase) were associated with overnight observation, while radial-only access OR: 2.45 (95% CI: 2.03-2.96, p < 0.001) had the strongest association with SDD. In the SDD, 2 (0.4%) of 514 patients were readmitted, due to retroperitoneal bleeding (n = 1) and ischemic stroke (n = 1)., Conclusion: The overall frequency of SDD after CTO PCI was 13% and has been increasing over time. SDD is feasible in select patients following CTO PCI, and radial-only access had the strongest association with SDD., (© 2023 Wiley Periodicals LLC.)

Background: Intravascular ultrasound (IVUS) can assist percutaneous coronary intervention (PCI) of chronic total occlusions (CTO)., Methods: We analyzed 8,983 CTO PCIs performed in 8,771 patients between 2012 and 2022 at 39 centers., Results: Overall, IVUS was used in 44.5% of the cases, for crossing in 11.5% and for stent optimization in 33.1%. IVUS for stent optimization was used more often for complex lesions with higher prevalence of calcification (51.2% vs 34.3%; P<.001); was associated with lower air kerma radiation dose (1.78 [1.00, 3.09] vs 2.30 (1.35, 3.91) min, P<.001) and contrast volume (190 [138, 258] vs 220 [160, 300] ml, P<.001). Among cases with successful guidewire crossing, those that used IVUS for stent optimization had higher technical (99.3% vs 96.3%; P<.001) and procedural (96.1% vs 94.6%, P=.002) success rates and similar major adverse complication event rates (2.04% vs 1.62%; P=.176). The use of IVUS for stent optimization significantly increased over time., Conclusion: In a contemporary, multicenter registry, IVUS was used in 44.5% and its use for stent optimization significantly increased over time. Cases where IVUS was used for stent optimization had higher technical and procedural success and similar risk of complications compared with cases where IVUS was not used for stent optimization.

Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is associated with high incidence of complications. We queried PubMed and the Cochrane Library (last search: October 26, 2022) for CTO PCI-specific periprocedural complication risk scores. We identified 8 CTO PCI-specific risk scores: (1) Angiographic coronary artery perforation (OPEN-CLEAN [Outcomes, Patient Health Status, and Efficiency iN (OPEN) Chronic Total Occlusion (CTO) Hybrid Procedures - CABG, Length (occlusion), EF <50%, Age, CalcificatioN] perforation, c-statistic 0.75): previous coronary artery bypass graft surgery, occlusion length 20 to 60 mm or ≥60 mm, left ventricular ejection fraction (LVEF) <50%, age 50 to 70 years or ≥70 years, heavy calcification. (2) Major adverse cardiovascular events (MACE) (PROGRESS-CTO complication, c-statistic 0.76): age >65 years, lesion length ≥23 mm, retrograde strategy, and (3) MACE (PROGRESS-CTO MACE, c-statistic 0.74): age ≥65 years, female gender, moderate/severe calcification, blunt/no stump, anterograde dissection and re-entry (ADR) or retrograde strategy. (4) All-cause mortality (PROGRESS-CTO mortality, c-statistic 0.80): age ≥65, moderate/severe calcification, LVEF ≤45%, ADR or retrograde strategy. (5) Perforation requiring pericardiocentesis (PROGRESS-CTO pericardiocentesis, c-statistic 0.78): age ≥65 years, moderate/severe calcification, female gender, ADR or retrograde strategy. (6) Acute myocardial infarction (PROGRESS-CTO acute myocardial infarction, c-statistic 0.72): previous coronary artery bypass graft surgery, atrial fibrillation, blunt/no stump. (7) Perforation requiring any treatment (PROGRESS-CTO perforation, c-statistic 0.74): age ≥65 years, moderate/severe calcification, blunt/no stump, ADR, or retrograde strategy. (8) Contrast-induced acute kidney injury (c-statistic 0.84): age ≥75, LVEF <40%, serum creatinine >1.5 mg/100 ml, serum albumin ≤30, 3040 g/L. There are 8 CTO PCI periprocedural risk scores that may facilitate risk assessment and procedural planning in patients who underwent CTO PCI., Competing Interests: Disclosures Dr. Azzalini received consulting fees from Teleflex, Abiomed, GE Healthcare (Little Chalfont, United Kingdom), Asahi Intecc, Philips, Abbott Vascular, and Cardiovascular Systems, Inc. Dr. Kearney received consulting fees from Abiomed, Abbott Vascular, Boston Scientific, Medtronic, Teleflex, and Cardiovascular Systems, Inc. Dr. Hirai received consulting fees from Siemens Healthineers, Asahi Intecc, and Zeon Medical. Dr. Burke: shareholder, Egg medical shareholder, MHI Ventures. Dr. Brilakis 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, and Teleflex; research support Boston Scientific, GE Healthcare; owner, Hippocrates LLC; shareholder: MHI Ventures, Cleerly Health, Stallion Medical. The remaining authors have no conflicts of interest to declare., (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.)

The impact of a previous failure on procedural techniques and outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study. We examined the clinical and angiographic characteristics and procedural outcomes of 9,393 patients who underwent 9,560 CTO PCIs at 42 United States and non-United States centers between 2012 and 2022. A total of 1,904 CTO lesions (20%) had a previous failed PCI attempt. Patients who underwent reattempt CTO PCI were more likely to have a family history of coronary artery disease (37% vs 31%, p <0.001) and dyslipidemia (87.9% vs 84.3%, p <0.001) but were less likely to have heart failure (25.1% vs 29.5%; p <0.001) and cerebrovascular disease (8.7% vs 10.4%, p = 0.04). Patients with previous failure had a higher Japanese CTO (3.33 ± 1.16 vs 2.12 ± 1.19, p <0.001) score and required longer procedure (120 vs 111 minutes, p <0.001) and fluoroscopy (46.9 vs 40.4 minutes, p <0.001) times and higher air kerma radiation dose (2.3 vs 2.1 gray, p = 0.013). Technical success rates (84.3% vs 86.5%, p = 0.011) were lower in patients with a previous failure compared with patients who underwent first-attempt CTO PCI with no significant difference in in-hospital major adverse cardiac events. After adjusting for potential confounders, a previous failure was not associated with technical failure. Operators performing >30 CTO PCIs annually were more likely to achieve technical success in patients with previous failure. In conclusion, a previous failed CTO PCI attempt was associated with higher lesion complexity, longer procedure time, and lower technical success; however, the association with lower technical success did not remain significant in multivariable analysis., Competing Interests: Disclosures Dr. Choi reports Medtronic advisory board. Dr. Poommipanit: 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. Jaber has received fees from Medtronic and proctoring fees from Abbott. Dr. Rinfret has received fees from Abbott Vascular, Abiomed, Boston Scientific, and SoundBite Medical and has been a consultant for Teleflex. Dr. Nicholson has been a proctor for and on the speaker bureau and advisory boards for Abbott Vascular, Boston Scientific, and Asahi Intecc and he reports intellectual property with Vascular Solutions. Dr. Jaffer has done sponsored research for Canon, Siemens, Shockwave, Teleflex, Mercator, and Boston Scientific and has been a consultant for Boston Scientific, Siemens, Magenta Medical, IMDS, Asahi Intecc, Biotronik, Philips, and Intravascular Imaging Inc; has equity interest in Intravascular Imaging Inc, DurVena; and has the right to receive royalties through Massachusetts General Hospital licensing arrangements with Terumo, Canon, and Spectrawave. Dr. Ybarra reports consultant for SoundBite Medical; speaker honoraria for Abbott Vascular. Dr. Rinfret reports consultant for Boston Scientific, Teleflex, Abbott Vascular, Biotronik, and SoundBite Medical Dr. Alaswad has been a consultant and speaker for Boston Scientific, Abbott Cardiovascular, Teleflex, and CSI. Dr. Karmpaliotis has received honoraria from Boston Scientific, Teleflex, Abiomed, and Abbott Vascular and has equity in Saranas, SoundBite Medical, Nanowear, and Traverse Vascular. Dr. Brilakis reports 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; research support: Boston Scientific, GE Healthcare; owner, Hippocrates LLC; shareholder: MHI Ventures, Cleerly Health, Stallion Medical. The remaining authors have no conflicts of interest to declare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) lesions can be challenging to perform. In the present review we summarize recent publications in this rapidly evolving area grouped according to indications, outcomes, technique, and complications.

Background: There are limited data on the use of bivalirudin for chronic total occlusion (CTO) percutaneous coronary intervention (PCI)., Methods: We compared CTO-PCIs performed using bivalirudin vs unfractionated heparin in the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO; NCT02061436). The primary endpoint was net adverse cardiac events (NACE), defined as major adverse cardiac events (MACE) and vascular complications., Results: Between 2012 and 2022, a total of 73 of 9723 procedures (0.75%) were performed using bivalirudin. The J-CTO score (2.4 ± 1.2 vs 2.4 ± 1.3; P=.73) and the PROGRESS-CTO score (1.4 ± 0.9 vs 1.2 ± 1.0; P=.31) were similar in both groups, and the retrograde approach was used less often in the bivalirudin group (15% vs 30%; P<.01). Procedural success (89% vs 85%; P=.35), in-hospital NACE (1.4% vs 2.1%; P>.99), incidence of MACE (0% vs 0.76%; P=.64), and vascular access complications (1.4% vs 0.9%; P=.48) were not different between the 2 groups. On multivariable analysis, use of bivalirudin was not associated with an increased risk of NACE (odds ratio, 0.99; 95% confidence interval, 0.13-7.27)., Conclusion: Bivalirudin is infrequently used during retrograde CTO-PCI. While the incidence of adverse events was similar with unfractionated heparin, larger studies are needed to assess the safety of bivalirudin.

Background: Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is associated with a considerable risk of complications, and risk stratification is of utmost importance., Aims: To assess the clinical usefulness of the recently developed PROGRESS-CTO (NCT02061436) complication risk scores in an independent cohort., Methods: Individual patient data pooled analysis of 3 registries was performed., Results: 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)., Conclusion: 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., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Background: Proximal cap ambiguity is a key parameter in the global chronic total occlusion (CTO) percutaneous coronary intervention (PCI) crossing algorithm., Methods: We examined the baseline characteristics and procedural outcomes of 9718 CTO PCIs performed in 9498 patients at 41 US and non-US centers between 2012 and 2022., Results: Proximal cap ambiguity was present in 35% of CTO lesions. Patients whose lesions had proximal cap ambiguity were more likely to have had prior coronary artery bypass graft surgery (37% vs. 24%; p < 0.001). Lesions with proximal cap ambiguity were more complex with higher J-CTO score (3.1 ± 1.0 vs. 2.0 ± 1.2; p < 0.001) and lower technical (79% vs. 90%; p < 0.001) and procedural (77% vs. 89%; p < 0.001) success rates compared with nonambiguous CTO lesions. The incidence of major adverse cardiovascular events (MACE) was higher in cases with proximal cap ambiguity (2.5% vs. 1.7%; p < 0.001). The retrograde approach was more commonly used among cases with ambiguous proximal cap (50% vs. 21%; p < 0.001) and was more likely to be the final successful crossing strategy (29% vs. 13%; p < 0.001). The antegrade dissection and re-entry (ADR) "move-the-cap" techniques were also more common among cases with proximal cap ambiguity., Conclusions: Proximal cap ambiguity in CTO lesions is associated with higher utilization of the retrograde approach and ADR, lower technical and procedural success rates, and higher incidence of in-hospital MACE., (© 2023 Wiley Periodicals LLC.)

Background: Although high body mass index (BMI) is a known risk factor for the development of cardiovascular diseases, people who are overweight or obese often have better outcomes after cardiac procedures. Whether this "obesity paradox" is observed in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is unknown. Therefore, we examined the association of BMI with the outcomes of CTO-PCI in patients from the large, multicenter PROGRESS-CTO registry after stratifying patients into 3 BMI groups.

Background: The impact of occlusion length on the procedural techniques and outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study., Methods: We examined the clinical and angiographic characteristics and procedural outcomes of 10,335 CTO PCIs at 42 US and non-US centers between 2012 and 2022. The cohort was divided into two groups based on lesion length (≥20 mm vs. <20 mm)., Results: Long lesions were present in 7208 (70%) patients. Comorbidities were more common in patients with long CTOs. Compared with short lesions, long lesions had higher J-CTO score (2.8 ± 1.1 vs. 1.3 ± 1; p < 0.001) and retrograde wiring was more often the initial (15.5% vs. 4.0%; p < 0.001) and successful (22.8% vs. 8.2%; p < 0.001) crossing strategy. Long lesions were more likely to require longer procedure (123 vs. 91 min; p < 0.001) and fluoroscopy (47.1 vs. 32.2 min; p < 0.001) time, larger contrast volume (218 vs. 200 mL; p < 0.001) and higher air kerma radiation dose (2.4 vs. 1.7 Gy; p < 0.001). After adjusting for potential confounders, long lesions were associated with lower technical success (odds ratio [OR]: 0.91 per 10 mm increase; 95% confidence interval [CI]: 0.88, 0.94) and higher major adverse cardiovascular events (MACE) (OR: 1.08 per 10 mm increase; 95% CI: 1.02, 1.15)., Conclusions: CTO PCI of long occlusions is independently associated with lower rates of technical success and higher rates of in-hospital MACE., (© 2023 Wiley Periodicals LLC.)

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: Guidewires and microcatheters are critical to the success of chronic total occlusion (CTO) percutaneous coronary intervention (PCI)., Methods: We examined equipment utilization in 11,202 CTO-PCIs performed in 10,952 patients at 42 United States (US) and non-US centers between 2012 and 2022., Results: Antegrade-only crossing was attempted in 7628 CTO-PCIs (68%) and the retrograde approach was used in 3574 CTO-PCIs (32%). The median number of guidewires used during antegrade wiring increased with lesion complexity from 3 (interquartile range [IQR], 2-4) for J-CTO score of 0 to 5 (IQR, 4-7) for J-CTO score of 5 (P<.001). Antegrade-only procedures had higher technical (90% vs 79%; P<.001) and procedural success (89% vs 77%; P<.001) compared with retrograde procedures. In antegrade-only cases, Pilot 200 (28%; Abbott Vascular) and Fielder XT (24%; Asahi Intecc) were the most frequently used guidewires, while Corsair (21%; Asahi Intecc) and Turnpike Spiral (20%; Vascular Solutions) were the most commonly used microcatheters. In retrograde cases, Sion (32%; Asahi Intecc) was the most common guidewire used, followed by Sion Black (22%; Asahi Intecc), Pilot 200 (22%), and Suoh 03 (19%; Asahi Intecc), while Corsair (16%) and Turnpike LP (11%) were the most commonly used microcatheters. The most successful guidewire for collateral crossing was the Sion (32%), followed by Sion Black (15%) and Suoh 03 (11%)., Conclusion: Polymer-jacketed guidewires are the most commonly used guidewires for antegrade wiring, while non-polymer-jacketed, torquable guidewires are the most frequently used guidewires for retrograde techniques. Turnpike and Corsair are the most commonly used microcatheters in CTO-PCI.

Background: There is limited data on the impact of a second attending operator on chronic total occlusion (CTO) percutaneous coronary intervention (PCI) outcomes., Methods: We analyzed the association between multiple operators (MOs) (>1 attending operator) and procedural outcomes of 9296 CTO PCIs performed between 2012 and 2021 at 37 centers., Results: CTO PCI was performed by a single operator (SO) in 85% of the cases and by MOs in 15%. Mean patient age was 64.4 ± 10 years and 81% were men. SO cases were more complex with higher Japan-CTO (2.38 ± 1.29 vs. 2.28 ± 1.20, p = 0.005) and Prospective Global Registry for the Study of Chronic Total Occlusion Intervention scores (1.13 ± 1.01 vs. 0.97 ± 0.93, p < 0.001) compared with MO cases. Procedural time (131 [87, 181] vs. 112 [72, 167] min, p < 0.001), fluoroscopy time (49 [31, 76] vs. 42 [25, 68] min, p < 0.001), air kerma radiation dose (2.32 vs. 2.10, p < 0.001), and contrast volume (230 vs. 210, p < 0.001) were higher in MO cases. Cases performed by MOs and SO had similar technical (86% vs. 86%, p = 0.9) and procedural success rates (84% vs. 85%, p = 0.7), as well as major adverse complication event rates (MACE 2.17% vs. 2.42%, p = 0.6). On multivariable analyses, MOs were not associated with higher technical success or lower MACE rates., Conclusion: In a contemporary, multicenter registry, 15% of CTO PCI cases were performed by multiple operators. Despite being more complex, SO cases had lower procedural and fluoroscopy times, and similar technical and procedural success and risk of complications compared with MO cases., (© 2023 Wiley Periodicals LLC.)

Coronary artery perforation is one of the most common and feared complications of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We evaluated the utility of the recently presented OPEN-CLEAN (Coronary artery bypass graft, Length of occlusion, Ejection fraction, Age, calcificatioN) perforation score in an independent multicenter CTO PCI dataset. Of the 2,270 patients who underwent CTO PCI at 7 centers, 150 (6.6%) suffered coronary artery perforation. Patients with perforations were older (69 ± 10 vs 65 ± 10, p <0.001), more likely to be women (89% vs 82%, p = 0.010), more likely to have history of previous coronary artery bypass graft (38% vs 20%, p <0.001), and unfavorable angiographic characteristics such as blunt stump (64% vs 42%, p <0.001), proximal cap ambiguity (51% vs 33%, p <0.001), and moderate-severe calcification (57% vs 43%, p = 0.001). Technical success was lower in patients with perforations (69% vs 85%, p <0.001). The area under the receiver operating characteristic curve of the OPEN-CLEAN perforation risk model was 0.74 (95% confidence interval 0.68 to 0.79), with good calibration (Hosmer-Lemeshow p = 0.72). We found that the CTO PCI perforation risk increased with higher OPEN-CLEAN scores: 3.5% (score 0 to 1), 3.1% (score 2), 5.3% (score 3), 7.1% (score 4), 11.5% (score 5), 19.8% (score 6 to 7). In conclusion, given its good performance and ease of preprocedural calculation, the OPEN-CLEAN perforation score appears to be useful for quantifying the perforation risk for patients who underwent CTO PCI., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Coronary artery perforation is a feared complication of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) and often leads to serious adverse clinical events., Aims: We sought to develop a risk score to predict clinical coronary artery perforation in patients undergoing CTO PCI., Methods: We analysed clinical and angiographic parameters from 9,618 CTO PCIs in the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO). Logistic regression prediction modelling was used to identify variables independently associated with clinical perforation, and the model was internally validated with bootstrapping. Clinical coronary artery perforation was defined as any perforation requiring treatment., Results: The incidence of clinical coronary perforation was 3.8% (n=367). Five factors were independently associated with perforation and were included in the score: patient age ≥65 years +1 point (odds ratio [OR] 1.79, 95% confidence interval [CI]: 1.37-2.33), moderate/severe calcification +1 point (OR 1.85, 95% CI: 1.41-2.42), blunt/no stump +1 point (OR 1.45, 95% CI: 1.10-1.92), use of antegrade dissection and re-entry +1 point (OR 2.43, 95% CI: 1.61-3.69), and use of the retrograde approach +2 points (OR 4.02, 95% CI: 2.95-5.46). The resulting score showed acceptable performance on receiver operating characteristic (ROC) curve (area under the curve [AUC]: 0.741, 95% CI: 0.712-0.773). The Hosmer-Lemeshow test indicated a good fit (p=0.991), and internal validation with bootstrapping demonstrated good agreement with the model with observed AUC: 0.736 (95% bias-corrected CI: 0.706-0.767)., Conclusions: The PROGRESS-CTO perforation score may be a useful tool for predicting clinical coronary perforation during CTO PCI.

Background: The prevalence and outcomes of patients who presented with an acute coronary syndrome (ACS) and underwent chronic total occlusion (CTO) percutaneous coronary intervention (PCI) have received limited study., Methods: We examined the clinical characteristics and procedural outcomes of ACS patients who underwent CTO-PCI in the Prospective Global Registry for the Study of CTO Intervention (PROGRESS-CTO; NCT02061436)., Results: Of the 8826 patients who underwent CTO-PCI between 2012 and 2022 at 38 centers, 558 (6.3%) presented with ACS. ACS presentation was with non-ST-segment elevation myocardial infarction (MI) in 54%, unstable angina in 33%, and ST-segment elevation MI in 6.5%. ACS patients were older (66 ± 11 years vs 64 ± 10 years; P<.001) and had higher prevalence of comorbidities such as diabetes mellitus (48% vs 42%; P=.02), prior MI (52% vs 45%; P<.01), and lower left ventricular ejection fraction (49 ± 14% vs 51 ± 13%; P<.01). While the PROGRESS-CTO score (1.4 ± 1.0 vs 1.2 ± 1.0; P<.001) was higher in the ACS group, the J-CTO score was comparable (2.3 ± 1.2 vs 2.4 ± 1.3; P=.68). Technical success (88% vs 86%; P=.12) and the incidence of in-hospital major adverse cardiovascular event (MACE) (0.9% vs 2.1%; P=.06) and adverse events at 3-month follow-up (3.4% vs 7.2%; Kaplan-Meier log-rank P=.16) were similar between ACS and non-ACS patients, respectively., Conclusion: Approximately 6% of patients who underwent CTO-PCI presented with an ACS. Technical success, in-hospital MACE, and the incidence of adverse events up to 3 months were similar between patients who presented with vs without an ACS.

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: Preprocedural coronary computed tomography angiography (CCTA) can be useful in procedural planning for chronic total occlusion (CTO) percutaneous coronary intervention (PCI)., Methods: 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., Results: 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)., Conclusion: 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., Competing Interests: Declaration of Competing Interest Dr. Jaffer: Sponsored research: Canon, Siemens, Shockwave, Teleflex, Mercator, Boston Scientific; Consultant: Boston Scientific, Siemens, Magenta Medical, IMDS, Asahi Intecc, Biotronik, Philips, Intravascular Imaging. Equity interest – Intravascular Imaging Inc., DurVena. Massachusetts General Hospital – licensing arrangements: Terumo, Canon, Spectrawave, for which FAJ has right to receive royalties. Dr. Doshi: speaker's bureau for Abbott Vascular, Boston Scientific, and Medtronic and research support from Biotronik. Dr. Alaswad: consultant and speaker for Boston Scientific, Abbott Cardiovascular, Teleflex, and CSI. Dr. Khatri: Personal Honoria for proctoring and speaking: Abbott Vascular, Asahi Intecc, Terumo, Boston Scientific. Dr. Davies: honoraria/consulting from Medtronic, Seimens Healthineers and Asahi intec. Dr. Mitul Patel: Consulting Honoraria from Abbott, Medtronic, Terumo, Cardiovascular Systems, Inc. Dr. Rinfret: Consultant for Boston Scientific, Teleflex, Abbott Vascular, Biotronik, and SoundBite Medical. Dr. Jaber: Member of the advisory board for Medtronic and has received proctoring fees from Abbott Vascular. Dr. Nicholson: reports speakers bureau, consulting, honoraria, advisory board for Abbott Vascular, Asahi Intecc, Boston Scientific, Corindus/Siemens, and Medtronic. Dr. Abi Rafeh: CTO Proctor and consultant for Boston Scientific and Abbott Vascular. Dr. ElGuindy: Consulting Honoraria: Medtronic, Boston Scientific, Asahi Intecc, Abbott; Proctorship fees: Medtronic, Boston Scientific, Asahi Intecc, Terumo; Educational grants: Medtronic. 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), ControlRad, CSI, Elsevier, GE Healthcare, IMDS, InfraRedx, Medicure, Medtronic, Opsens, Siemens, and Teleflex; research support: Boston Scientific, GE Healthcare; owner, Hippocrates LLC; shareholder: MHI Ventures, Cleerly Health, Stallion Medical. Others: None., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Background: The comparative efficacy and safety of parallel wiring versus antegrade dissection and re-entry (ADR) in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is controversial., Methods: We compared the clinical and angiographic characteristics and outcomes of parallel wiring versus ADR after failed antegrade wiring in a large, multicenter CTO PCI registry., Results: A total of 1725 CTO PCI procedures with failed antegrade wiring with a single wire were approached with parallel wiring (692) or ADR (1033) at the discretion of the operator. ADR patients were older (65 ± 10 vs. 62 ± 10, years, p &lt; 0.001) and had higher prevalence of comorbidities, such as diabetes mellitus (43% vs. 32%, p &lt; 0.001), prior coronary artery bypass graft surgery (31% vs. 19%, p &lt; 0.001), and lower left ventricular ejection fraction (50 ± 14 vs. 53 ± 11%, p &lt; 0.001). The ADR group had higher J-CTO (2.8 ± 1.1 vs. 2.1 ± 1.3, p &lt; 0.001) and PROGRESS-CTO (1.6 ± 1.1 vs. 1.2 ± 1.0, p &lt; 0.001) scores. Equipment use including guidewires, balloons, and microcatheters was higher, and the procedures lasted longer in the ADR group. Technical success (78% vs. 75%, p = 0.046) and major adverse cardiovascular events (composite of all-cause mortality, stroke, acute myocardial infarction, emergency surgery or re-PCI, and pericardiocentesis) (3.7% vs. 1.9%, p = 0.029) were higher in the ADR group, with similar procedural success (75% vs. 73%, p = 0.166)., Conclusion: In lesions that could not be crossed with antegrade wiring, ADR was associated with higher technical but not procedural success, and also higher MACE compared with parallel wiring., (© 2022 Wiley Periodicals LLC.)

Use of radial access for chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has been increasing. We examined the clinical characteristics and procedural outcomes of patients who underwent CTO PCI with radial versus femoral access in the Prospective Global Registry for the Study of CTO Intervention (PROGRESS-CTO, NCT02061436). Of 10,954 patients who underwent CTO PCI at 55 centers in 7 countries between 2012 and 2022, 2578 (24%) had a radial only approach. Patients who underwent radial only access were younger (63 ± 10 vs. 65 ± 10, years, p &lt; 0.001), more likely to be men (84% vs. 81%, p = 0.001), and had significantly lower prevalence of comorbidities compared with the femoral access group including diabetes mellitus (39% vs. 45%, p &lt; 0.001) and coronary artery bypass graft surgery (57% vs. 64%, p &lt; 0.001). In addition, radial only cases had lower angiographic complexity with lower J-CTO and PROGRESS-CTO scores. After adjusting for potential confounders, radial only access was associated with lower risk of access site complications (odds ratio [OR]: 0.45, 95% confidence interval [CI]: 0.22-0.91), similar technical success (OR: 0.87, 95% CI: 0.74-1.04) and major adverse cardiovascular events (MACE) (OR: 0.65, 95% CI: 0.40-1.07), compared with the femoral access group. Radial only access was used in 24% of CTO PCIs and was associated with lower access site complications, and similar technical success and MACE as compared with the femoral access group., (© 2022 Wiley Periodicals LLC.)

Objectives: Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) can improve patient symptoms, but it remains controversial whether it impacts subsequent clinical outcomes., Methods: In this systematic review and meta-analysis, we queried PubMed, ScienceDirect, Cochrane Library, Web of Science, and Embase databases (last search: September 15, 2021). We investigated the impact of CTO-PCI on clinical events including all-cause mortality, cardiovascular death, myocardial infarction (MI), major adverse cardiovascular event (MACE), stroke, subsequent coronary artery bypass surgery, target-vessel revascularization, and heart failure hospitalizations. Pooled analysis was performed using a random-effects model., Results: A total of 58 publications with 54,540 patients were included in this analysis, of which 33 were observational studies of successful vs failed CTO-PCI, 19 were observational studies of CTO-PCI vs no CTO-PCI, and 6 were randomized controlled trials (RCTs). In observational studies, but not RCTs, CTO-PCI was associated with better clinical outcomes. Odds ratios (ORs) and 95% confidence intervals (CIs) for all-cause mortality, MACE, and MI were 0.52 (95% CI, 0.42-0.64), 0.46 (95% CI, 0.37-0.58), 0.66 (95% CI, 0.50-0.86), respectively for successful vs failed CTO-PCI studies; 0.38 (95% CI, 0.31-0.45), 0.57 (95% CI, 0.42-0.78), 0.65 (95% CI, 0.42-0.99), respectively, for observational studies of CTO-PCI vs no CTO-PCI; 0.72 (95% CI, 0.39-1.32), 0.69 (95% CI, 0.38-1.25), and 1.04 (95% CI, 0.46-2.37), respectively for RCTs., Conclusions: CTO-PCI is associated with better subsequent clinical outcomes in observational studies but not in RCTs. Appropriately powered RCTs are needed to conclusively determine the impact of CTO-PCI on clinical outcomes.

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.)

Coronary artery perforation is a feared complication of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Our objective was to describe the incidence, mechanisms, treatment, and outcomes of coronary artery perforation during CTO PCI. We analyzed the baseline clinical and angiographic characteristics and procedural outcomes of 10,454 CTO PCIs performed in 10,219 patients between 2012 and 2022. The incidence of coronary perforation was 4.9% (n = 503). Patients who experienced coronary perforation were older and were more likely to have had previous coronary artery bypass graft surgery. Procedures that resulted in perforation were more complex, with higher Japanese CTO and Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO) scores. Technical (66% vs 87%, p &lt;0.001) and procedural (55% vs 87%, p &lt;0.001) success rates were lower in perforation cases. The CTO target vessel was the most common perforation site (66%). The retrograde approach was responsible for the perforation in 47% of cases, and guidewire exit was the most common perforation mechanism. The proportion of Ellis class 1, 2, 3, and 3 -"cavity spilling" coronary perforations was 20%, 41%, 28%, and 11%, respectively. In 52% of perforations, 1 or more interventions were required: prolonged balloon inflation (23%), covered stent deployment (21%), coil embolization (6%), and/or autologous fat embolization (4%). Tamponade requiring pericardiocentesis occurred in 69 patients (14%). The incidence of major adverse cardiovascular events was higher in perforation cases (18% vs 1.3%, p &lt;0.001). In conclusion, coronary artery perforation occurred in 4.9% of CTO PCIs performed by experienced operators and was associated with lower technical success and higher in-hospital major adverse cardiovascular events., Competing Interests: Disclosures Dr. Alaswad: Consultant and speaker for Boston Scientific, Abbott Cardiovascular, Teleflex, and Cardiovascular Systems, Inc. Dr. Karmpaliotis: Honoraria - Boston Scientific and Abbot Vascular; Equity: Saranas, Soundbite, Traverse Vascular. Dr. Jaffer: Sponsored research: Canon, Siemens, Shockwave, Teleflex, Mercator, and Boston Scientific; Consultant: Boston Scientific, Siemens, Magenta Medical, International Medical Device Solutions, Asahi Intecc, Biotronik, Philips, Intravascular Imaging Inc. Equity interest: Intravascular Imaging Inc, DurVena. Massachusetts General Hospital - licensing arrangements: Terumo, Canon, and Spectrawave, for which Dr. Jaffer has the right to receive royalties. Dr. Khatri: Personal Honoria for proctoring and speaking: Abbott Vascular, Asahi Intecc Co., Ltd., Terumo, and Boston Scientific. Dr. Poommipanit: Asahi Intecc Co., Ltd., Abbott, Vascular-Consultant. Dr. Jaber: Medtronic and proctoring fees from Abbott. Dr. Rinfret: Abbott Vascular, Abiomed, Boston Scientific Corporation, SoundBite Medical, Teleflex consultant. Dr. Nicholson: Is a proctor and on the speakers' bureau and the advisory board for Abbott Vascular, Boston Scientific, and Asahi Intecc Co., Ltd.; he reports intellectual property with Vascular Solutions. Dr. Patel: Consulting Honoraria from Abbott, Medtronic, Terumo, and Cardiovascular Systems, Inc. Dr. Mahmud: Consultant for Abiomed, Medtronic, and Boston Scientific, and chairs multiple Data, Safety, and Monitoring Boards. Dr. Davies: Honoraria from Asahi Intecc Co., Ltd., Boston Scientific, Medtronic, and Siemens Healthineers, in addition to being a member of an advisory board for Shockwave Medical. Dr. Kerrigan: Consultant to Abiomed, Asahi Intecc Co., Ltd., Biotronik, Cordis, Boston Scientific, Ischemaview Inc., Osprey Medical, Penumbra, Philips, and Teleflex. Dr. Abi-Rafeh: Proctor and speaker honoraria for Boston Scientific and Abbott Vascular. Dr. ElGuindy: Consulting honoraria: Medtronic, Boston Scientific, Asahi Intecc Co., Ltd., Abbott; Proctorship fees: Medtronic, Boston Scientific, Asahi Intecc Co., Ltd., and Terumo; Educational grants: Medtronic. Dr. Brilakis: Consulting/speaker honoraria from Abbott Vascular, American Heart Association (Associate Editor: Circulation), Amgen, Asahi Intecc Co., Ltd., Biotronik, Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), ControlRad, CSI, Elsevier, GE Healthcare, IMDS, InfraRedx, Medicure, Medtronic, Opsens, Siemens, and Teleflex; Research support: Boston Scientific, GE Healthcare; owner at Hippocrates LLC; shareholder at Minneapolis Heart Institute Ventures, Cleerly Health, and Stallion Medical. The remaining authors have no conflicts of interest to declare., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: The use of intravascular lithotripsy (IVL) in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study., Methods: We analyzed the baseline clinical and angiographic characteristics and procedural outcomes of 82 CTO PCIs that required IVL at 14 centers between 2020 and 2022., Results: During the study period, IVL was used in 82 of 3301 (2.5%) CTO PCI procedures (0.4% in 2020 and 7% in 2022; p for trend < 0.001). Mean patient age was 69 ± 11 years and 79% were men. The prevalence of hypertension (95%), diabetes mellitus (62%), and prior PCI (61%) was high. The most common target vessel was the right coronary artery (54%), followed by the left circumflex (23%). The mean J-CTO and PROGRESS-CTO scores were 2.8 ± 1.1 and 1.3 ± 1.0, respectively. Antegrade wiring was the final successful crossing strategy in 65% and the retrograde approach was used in 22%. IVL was used in 10% of all heavily calcified lesions and 11% of all balloon undilatable lesions. The 3.5 mm lithotripsy balloon was the most commonly used balloon (28%). The mean number of pulses per lithotripsy run was 33 ± 32 and the median duration of lithotripsy was 80  (interquartile range: 40-103) seconds. Technical and procedural success was achieved in 77 (94%) and 74 (90%) cases, respectively. Two (2.4%) Ellis Class 2 perforations occurred after IVL use and were managed conservatively., Conclusion: IVL is increasingly being used in CTO PCI with encouraging outcomes., (© 2022 Wiley Periodicals LLC.)

Objectives: There are limited data on the association of operator volume with the outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI)., Methods: We analyzed the association between operator volume and procedural outcomes of 7035 CTO-PCIs performed between 2012 and February 2021 at 30 centers., Results: The study population was divided into 3 groups based on annual operator CTO-PCI volume: low-volume operators (LVO: &lt;30 cases/year; 39.7% of the cases); medium-volume operators (MVO: 30-60 cases/year; 25.7% of the cases); and high-volume operators (HVO: &gt;60 cases/ year; 34.6% of the cases). Mean patient age was 64.4 ± 10 years and 82% were men. Cases performed by HVOs were more complex, with higher J-CTO score compared with cases performed by MVOs and LVOs (2.72 ± 1.27 vs 2.39 ± 1.19 vs 2.12 ± 1.27, respectively; P&lt;.001). Moderate/severe proximal vessel tortuosity (35% vs 23% vs 20%; P&lt;.001) and proximal cap ambiguity (44% vs 34% vs 32%; P&lt;.001) was also more common in the HVO group. Cases performed by HVOs had higher technical success rates (87.9% vs 86.9% vs 82.6%; P&lt;.001), but also higher rates of periprocedural major cardiac adverse events compared with MVOs and LVOs (3.08% vs 2.71% vs 1.50%; P&lt;.01). On multivariable analyses, HVOs and MVOs were associated with higher technical success., Conclusions: In a contemporary, multicenter registry, 40% of CTO-PCI cases are performed by LVOs performing &lt;30 cases per year. Cases performed by HVOs were associated with higher technical and procedural success, but also higher periprocedural major complication rates, potentially due to higher lesion complexity.

Background: The prevalence, treatment, and outcomes of balloon undilatable lesions encountered in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) have received limited study., Methods: 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)., Results: 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)., Conclusion: 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., (Copyright © 2022 Elsevier B.V. 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.

Background: Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is associated with increased risk of periprocedural complications. Estimating the risk of complications facilitates risk-benefit assessment and procedural planning., Objectives: This study sought to develop risk scores for in-hospital major adverse cardiovascular events (MACE), mortality, pericardiocentesis, and acute myocardial infarction (MI) in patients undergoing CTO PCI., Methods: The study analyzed the PROGRESS-CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention; NCT02061436) and created risk scores for MACE, mortality, pericardiocentesis, and acute MI. Logistic regression prediction modeling was used to identify independently associated variables, and models were internally validated with bootstrapping., Results: The incidence of periprocedural complications among 10,480 CTO PCIs was as follows: MACE 215 (2.05%), mortality 47 (0.45%), pericardiocentesis 83 (1.08%), and acute MI 66 (0.63%). The final model for MACE included ≥65 years of age (1 point), moderate-severe calcification (1 point), blunt stump (1 point), antegrade dissection and re-entry (ADR) (1 point), female (2 points), and retrograde (2 points); the final model for mortality included ≥65 years of age (1 point), left ventricular ejection fraction ≤45% (1 point), moderate-severe calcification (1 point), ADR (1 point), and retrograde (1 point); the final model for pericardiocentesis included ≥65 years of age (1 point), female (1 point), moderate-severe calcification (1 point), ADR (1 point), and retrograde (2 points); the final model for acute MI included prior coronary artery bypass graft surgery (1 point), atrial fibrillation (1 point), and blunt stump (1 point). The C-statistics of the models were 0.74, 0.80, 0.78, 0.72 for MACE, mortality, pericardiocentesis, and acute MI, respectively., Conclusions: The PROGRESS-CTO complication risk scores can facilitate estimation of the periprocedural complication risk in patients undergoing CTO PCI., Competing Interests: Funding Support and Author Disclosures The authors are grateful for the philanthropic support of our generous anonymous donors, and the philanthropic support of Drs. Mary Ann and Donald A. Sens, Mrs. Diane and Dr Cline Hickok, Mrs. Wilma and Mr. Dale Johnson, Mrs. Charlotte and Mr. Jerry Golinvaux Family Fund, the Roehl Family Foundation, and the Joseph Durda Foundation. The generous gifts of these donors to the Minneapolis Heart Institute Foundation's Science Center for Coronary Artery Disease helped support this research project. Dr Alaswad has served as a consultant and speaker for Boston Scientific, Abbott Cardiovascular, Teleflex, and CSI. Dr Davies has received honoraria from Boston Scientific, Medtronic, Siemens Healthineers, and Shockwave Medical. Dr ElGuindy has received consulting honoraria from Medtronic, Boston Scientific, Asahi Intecc, and Abbott; proctorship fees from Medtronic, Boston Scientific, Asahi Intecc, and Terumo; and educational grants from Medtronic. Dr Patel has received consulting honoraria from Abbott, Medtronic, Terumo, and Cardiovascular Systems. Dr Abi Rafeh has served as a CTO proctor and consultant for Boston Scientific and Abbott Vascular. Dr Karmpaliotis has received honoraria from Boston Scientific and Abbott Vascular; and owns equity in Saranas, Soundbite, and Traverse Vascular. Dr Khatri has received personal honoraria for proctoring and speaking from Abbott Vascular, Asahi Intecc, Terumo, and Boston Scientific. Dr Jaffer has performed sponsored research for Canon, Siemens, Shockwave, Teleflex, Mercator, and Boston Scientific; has served as a consultant for Boston Scientific, Siemens, Magenta Medical, IMDS, Asahi Intecc, Biotronik, Philips, and Intravascular Imaging; owns equity interest in Intravascular Imaging and DurVena; and his employer (Massachusetts General Hospital) has licensing arrangements with Terumo, Canon, and Spectrawave, for which Dr Jaffer has right to receive royalties. Dr Doshi has served on the Speakers Bureau for Abbott Vascular, Boston Scientific, and Medtronic; and received research support from Biotronik. Dr Jaber has served on the advisory board for Medtronic; and received proctoring fees from Abbott Vascular. Dr Yeh has received grant or contract support from Abiomed, AstraZeneca, BD Bard, Boston Scientific, Cook Medical, Medtronic, and Philips; and consulting fees from Abbott, Boston Scientific, Edwards Lifesciences, Medtronic, and Shockwave Medical outside the submitted work. Dr Burke is a stockholder of MHI Ventures and Egg Medical. Dr Brilakis has received consulting or 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), 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 of 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: An upfront (primary) retrograde strategy is often used in complex chronic total occlusion (CTO) percutaneous coronary intervention (PCI)., Methods: We examined the clinical, angiographic characteristics, and procedural outcomes of CTO PCIs that were approached with a primary retrograde strategy in the Prospective Global Registry for the Study of CTO Intervention (PROGRESS-CTO, NCT02061436)., Results: Of 10,286 CTO PCIs performed between 2012 and 2022, a primary retrograde strategy was used in 1329 (13%) with an initial technical success of 66%, and a final success of 83%. Patients who underwent successful versus unsuccessful primary retrograde cases had similar characteristics: age (65 ± 10 vs. 65 ± 9, years, p = 0.203), men (83% vs. 87%, p = 0.066), prior PCI (71% vs. 71%, p = 0.809), and prior coronary artery bypass graft surgery (52% vs. 53%, p = 0.682). The PROGRESS-CTO score (1.3 ± 0.9 vs. 1.6 ± 0.9, p < 0.001), air kerma radiation (3.9 ± 2.8 vs. 3.4 ± 2.6, gray, p = 0.013), and contrast use (294 ± 148 ml vs. 248 ± 128, ml, p < 0.001) were higher in the unsuccessful group, whereas the presence of interventional collaterals (95% vs. 72%, p < 0.001) and Werner collateral connection grade 2 (43% vs. 31%, p < 0.001) were higher in the successful group. On multivariable logistic regression analysis, the only variable associated with a successful primary retrograde strategy was the presence of interventional collaterals: odds ratio: 6.52 (95% confidence intervals; 3.5-12.1, p < 0.001)., Conclusion: Presence of interventional collaterals is independently associated with higher success rates with a primary retrograde strategy in CTO PCI., (© 2022 Wiley Periodicals LLC.)