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Objectives: There is limited data on race and outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). The authors sought to evaluate CTO PCI techniques and outcomes in different racial groups., Methods: We examined the baseline characteristics and procedural outcomes of 11 806 CTO PCIs performed at 44 US and non-US centers between 2012 and March 2023. In-hospital major adverse cardiac events (MACE) included death, myocardial infarction, repeat target-vessel revascularization, pericardiocentesis, cardiac surgery, and stroke prior to discharge., Results: The most common racial group was White (84.5%), followed by Black (5.7%), "Other" (3.9%), Hispanic (2.9%), Asian (2.4%), and Native American (0.7%). There were significant differences in the baseline characteristics between different racial groups. When compared with non-White patients, the retrograde approach and antegrade dissection re-entry were more likely to be the successful crossing strategies in White patients without any significant differences in technical success (86.4% vs 86.4%; P = .93), procedural success (84.8% vs 85.0%; P = .79), and in-hospital MACE (2.0% vs 1.5%; P = .15) between the 2 groups. The technical success rate was significantly higher in the "Other" racial group (91.0% vs 86.4% in White, 86.9% in Asian, 84.5% in Black, 84.5% in Hispanic, and 83.3% in Native American; P = .03) without any significant differences in procedural success or in-hospital MACE rates between the groups., Conclusions: Despite differences in baseline characteristics and procedural techniques, the procedural success and in-hospital MACE of CTO PCI were not significantly different between most racial groups.

Objectives: Ostial CTOs can be challenging to revascularize. We aim to describe the outcomes of ostial chronic total occlusion (CTO) percutaneous coronary intervention (PCI)., Methods: We examined the clinical and angiographic characteristics and procedural outcomes of 8788 CTO PCIs performed at 35 US and non-US centers between 2012 and 2022. In-hospital major adverse cardiac events (MACE) included death, myocardial infarction, urgent repeat target-vessel revascularization, tamponade requiring pericardiocentesis or surgery, and stroke., Results: Ostial CTOs constituted 12% of all CTOs. Patients with ostial CTOs had higher J-CTO score (2.9 ± 1.2 vs 2.3 ± 1.3; P less than .01). Ostial CTO PCI had lower technical (82% vs. 86%; P less than .01) and procedural (81% vs. 85%; P less than .01) success rates compared with non-ostial CTO PCI. Ostial location was not independently associated with technical success (OR 1.03, CI 95% 0.83-1.29 P =.73). Ostial CTO PCI had a trend towards higher incidence of MACE (2.6% vs. 1.8%; P =.06), driven by higher incidence of in-hospital death (0.9% vs 0.3% P less than.01) and stroke (0.5% vs 0.1% P less than .01). Ostial lesions required more often use of the retrograde approach (30% vs 9%; P less than .01). Ostial CTO PCI required longer procedure time (149 [103,204] vs 110 [72,160] min; P less than .01) and higher air kerma radiation dose (2.3 [1.3, 3.6] vs 2.0 [1.1, 3.5] Gray; P less than .01)., Conclusions: Ostial CTOs are associated with higher lesion complexity and lower technical and procedural success rates. CTO PCI of ostial lesions is associated with frequent need for retrograde crossing, higher incidence of death and stroke, longer procedure time and higher radiation dose.

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.)

Background: Distal vessel quality is a key parameter in the global chronic total occlusion (CTO) crossing algorithm., Objectives: The study sought to evaluate the association of distal vessel quality with the outcomes of CTO percutaneous coronary intervention., Methods: We examined the clinical and angiographic characteristics and procedural outcomes of 10,028 CTO percutaneous coronary interventions performed at 39 U.S. and non-U.S. centers between 2012 and 2022. A poor-quality distal vessel was defined as <2 mm diameter or with significant diffuse atherosclerotic disease. In-hospital major adverse cardiac events (MACE) included death, myocardial infarction, urgent repeat target vessel revascularization, tamponade requiring pericardiocentesis or surgery, and stroke., Results: A total of 33% of all CTO lesions had poor-quality distal vessel. When compared with good-quality distal vessels, CTO lesions with a poor-quality distal vessel had higher J-CTO (Japanese chronic total occlusion) scores (2.7 ± 1.1 vs 2.2 ± 1.3; P < 0.01), lower technical (79.9% vs 86.9%; P < 0.01) and procedural (78.0% vs 86.8%; P < 0.01) success, and higher incidence of MACE (2.5% vs 1.7%; P < 0.01) and perforation (6.4% vs 3.7%; P < 0.01). A poor-quality distal vessel was independently associated with technical failure and MACE. Poor-quality distal vessels were associated with higher use of the retrograde approach (25.2% vs 14.9%; P < 0.01) and higher air kerma radiation dose (2.4 [IQR: 1.3-4.0] Gy vs 2.0 [IQR: 1.1-3.5] Gy; P < 0.01)., Conclusions: A poor-quality distal vessel in CTO lesions is associated with higher lesion complexity, higher need for retrograde crossing, lower technical and procedural success, higher incidence of MACE and coronary perforation, and higher radiation dose., Competing Interests: Funding Support and Author Disclosures The authors are grateful for the philanthropic support of the 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, the 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 and Center for Coronary Artery Disease helped support this research project. Dr Allana has served as a consultant for Boston Scientific Corporation. Dr Alaswad has served as a consultant and speaker for Boston Scientific, Abbott Cardiovascular, Teleflex, and Cardiovascular Systems Inc. Dr Karmpaliotis has received honoraria from Boston Scientific, Abbott Vascular, and Abiomed; and owns equity in Saranas, Soundbite, and Traverse Vascular. Dr Jaffer has conducted sponsored research for Canon, Siemens, Shockwave, Teleflex, Mercator, Boston Scientific, HeartFlow, and Amarin; has served as a consultant for Boston Scientific, Siemens, Magenta Medical, International Medical Device Solutions, Asahi Intecc, Biotronik, Philips, Intravascular Imaging, and DurVena; owns equity interest in Intravascular Imaging Inc and DurVena; and his employer, Massachusetts General Hospital, has licensing arrangements with Terumo, Canon, and Spectrawave, for which he has the right to receive royalties. Dr Khatri has received personal honoraria for proctoring and speaking for Abbott Vascular, Medtronic, Terumo, and Shockwave Medical. Dr Poommipanit has served as a consultant for Medtronic, Asahi Intecc, Abbott Vascular, and Boston Scientific. Dr Patel has received consulting honoraria from Abbott, Medtronic, Terumo, and Cardiovascular Systems. Dr Mahmud has served as a consultant for Abiomed, Medtronic, and Boston Scientific; and has served as chair for multiple Data, Safety and Monitoring Boards. Dr Nicholson has served as a proctor and on the Speakers Bureau and advisory board for Abbott Vascular, Boston Scientific, and Asahi Intecc; and owns reports intellectual property with Vascular Solutions. Dr Jaber received received research and educational funds from Medtronic, Inari Medical; has served as a consultant for Medtronic, Inari Medical; has received a proctoring fees from Abbott Vascular; and has served on the advisory board for Medtronic. Dr Rinfret has served as a consultant for Abbott Vascular, Abiomed, Boston Scientific Corporation, SoundBite Medical, and Teleflex. Dr Abi-Rafeh has served as a proctor for and received speaker honoraria from Boston Scientific and Abbott Vascular. 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 Sandoval has served on the advisory board for Roche Diagnostics and Abbott Diagnostics without personal compensation; and as a speaker without personal financial compensation for Abbott Diagnostics. Dr Burke has received consulting and speaker honoraria from Abbott Vascular and Boston Scientific. Dr Brilakis has received consulting/speaker honoraria from Abbott Vascular, the American Heart Association (associate editor for 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 for 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: 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: We sought to examine the procedural and clinical outcomes of patients who underwent chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in the setting of acute myocardial infarction (AMI)., Methods: We assessed the clinical and procedural characteristics, technical success, procedural success, and in-hospital outcomes of 2314 patients who underwent CTO-PCI at 20 experienced centers between 2012 and 2017, classified according to whether or not they presented with AMI., Results: Mean patient age was 65 ± 10 years, 85% were men, and 154 (6.7%) presented with AMI (5.5% with non-ST segment elevation myocardial infarction, 1.1% with ST-segment elevation myocardial infarction). Compared with non-AMI patients who underwent CTO-PCI, AMI patients had higher prevalence of diabetes (56% vs 42%; P<.01) and lower median left ventricular ejection fraction (48% vs 54%; P<.001). The CTO angiographic characteristics were similar between the 2 groups. Compared with non-AMI patients undergoing CTO-PCI, AMI patients had more frequent use of antegrade wire escalation (86.0% vs 78.9%; P=.03) and more frequent use of hemodynamic support devices (16.2% vs 3.4%; P<.01), and were more likely to have a non-CTO lesion treated (34.0% vs 26.6%; P=.03). AMI and non-AMI patients had similar technical success (90% vs 87%; P=.26), procedural success (88% vs 85%; P=.38), and incidence of in-hospital MACE (2.6% vs 2.5%; P=.94)., Conclusion: CTO-PCI is performed infrequently in AMI patients and is associated with similar technical and procedural success rates and in-hospital major adverse cardiovascular event rates when compared with CTO-PCI performed in non-AMI patients.

Introduction: Percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) can be challenging, but high success rates (85-90%) are currently achieved at experienced centers with approximately 3% risk for a major periprocedural complication.Areas covered: CTO PCI complications can be categorized according to location such as cardiac and non-cardiac (vascular access complications, thromboembolic complications, contrast-related and radiation injury) complications. Cardiac complications are further subdivided into coronary (acute closure, perforation, and equipment loss or entrapment) and non-coronary (hypotension, myocardial infarction, tamponade, arrhythmias).Expert opinion: In this article, we review strategies to prevent and treat CTO PCI complications. Careful monitoring throughout the case enables prevention and early detection of a complication. If a complication occurs, rapid implementation of treatment using an algorithmic approach can minimize its adverse impact. [ABSTRACT FROM AUTHOR]

The article discusses the lessons learned from various randomized trials regarding the comparison between culprit lesion-only and complete revascularization in patients with ST-elevation myocardial infarction (STEMI).

The article discusses a study on the results of the Thrombus Aspiration in ST-Elevation Myocardial Infarction in Scandinavia trial (TASTE), a randomized clinical trial for patients with ST-segment elevation myocardial infarction.

We examine the one-year mortality rates from the STREAM trial, recently published in Circulation. [ABSTRACT FROM AUTHOR]

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

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