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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: Coronary artery dissection is a feared and potentially life-threatening complication of percutaneous coronary intervention (PCI)., Methods: We examined the clinical, angiographic, and procedural characteristics, and outcomes of coronary dissection at a tertiary care institution., Results: Between 2014 and 2019, unplanned coronary dissection occurred in 141 of 10,278 PCIs (1.4%). Median patient age was 68 (60, 78) years, 68% were men, and 83% had hypertension. The prevalence of diabetes (29%), and prior PCI (37%) was high. Most target vessels were significantly diseased: 48% had moderate/severe tortuosity and 62% had moderate/severe calcification. The most common cause of dissection was guidewire advancement (30%), followed by stenting (22%), balloon angioplasty (20%), and guide-catheter engagement (18%). TIMI flow was 0 in 33% and 1-2 in 41% of cases. Intravascular imaging was used in 17% of the cases. Stenting was used to treat the dissection in 73% of patients. There was no consequence of dissection in 43% of patients. Technical and procedural success was 65% and 55%, respectively. In-hospital major adverse cardiovascular events occurred in 23% of patients: 13 (9%) had an acute myocardial infarction (MI), 3 (2%) had emergency coronary artery bypass graft surgery, and 10 (7%) died. During a mean follow up of 1612 days, 28 (20%) patients died, and the rate of target lesion revascularization was 11.3% (n=16)., Conclusion: Coronary artery dissection is an infrequent complication of PCI, but is associated with adverse clinical outcomes, such as death and acute MI.

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.)