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Introduction: The American College of Cardiology (ACC), the American Heart Association (AHA), and the European Society of Cardiology (ESC) have been developing guidelines to assist clinicians in making evidence-based decisions., Materials and Methods: The current ACC/AHA and ESC guidelines for non-ST-segment elevation acute coronary syndromes (NSTE-ACS) that were updated in 2014 and 2015, respectively, were compared to assess the number of recommendations on the basis of class of recommendation and level of evidence (LOE), the sources cited, and the content., Results: The total number of recommendations in the ACC/AHA and ESC guidelines was 182 and 147, respectively. The recommendation class distribution of the ACC/AHA guidelines was 61.0% class I (compared with 61.9% in the ESC guidelines, P=0.865), 29.7% class II (compared with 32.0% in the ESC guidelines, P=0.653), and 9.3% class III (compared with 6.1% in the ESC guidelines, P=0.282). The LOE distribution among ACC/AHA guidelines was 15.9% LOE A (compared with 27.9% in the ESC guidelines, P=0.008), 50.0% LOE B (compared with 33.3% in the ESC guidelines, P=0.002), and 34.1% LOE C (compared with 38.8% in the ESC guidelines, P=0.377). The ACC/AHA guidelines cited 827 publications and the ESC guidelines cited 551 publications, 124 of which were shared by both sets of guidelines. The guidelines' approaches to NSTE-ACS were consistent, with minor differences in diagnostic and medical therapy recommendations., Conclusion: Overall, the ACC/AHA and ESC guidelines contain a comparable number of recommendations and provide similar guidance for the management of patients with NSTE-ACS.

A 62-year-old man was referred for percutaneous coronary intervention of a severe circumflex lesion. The guidewire became entangled in the previously implanted left anterior descending artery stent. The left main was engaged with a second guide catheter, followed by balloon dilations, various microcatheters, and laser atherectomy. The wire eventually fractured without protruding into the aorta. The circumflex lesion was stented with two stents, followed by left main stenting that covered the fragment. Caution should be used when wiring through stents; wire fracture can be treated with stent implantation, as long as the wire fragment does not protrude into the aorta.

Objectives: We sought to examine near-infrared spectroscopy (NIRS) imaging findings of aortocoronary saphenous vein grafts (SVGs)., Background: SVGs are prone to develop atherosclerosis similar to native coronary arteries. They have received little study using NIRS., Methods: We examined the clinical characteristics and imaging findings from 43 patients who underwent NIRS imaging of 45 SVGs at our institution between 2009 and 2016., Results: The mean patient age was 67 ± 7 years and 98% were men, with high prevalence of diabetes mellitus (56%), hypertension (95%), and dyslipidemia (95%). Mean SVG age was 7 ± 7 years, mean SVG lipid core burden index (LCBI) was 53 ± 60 and mean maxLCBI 4 mm was 194 ± 234. Twelve SVGs (27%) had lipid core plaques (2 yellow blocks on the block chemogram), with a higher prevalence in SVGs older than 5 years (46% vs. 5%, P = 0.002). Older SVG age was associated with higher LCBI (r = 0.480, P < 0.001) and higher maxLCBI 4 mm (r = 0.567, P < 0.001). On univariate analysis, greater annual total cholesterol exposure was associated with higher SVG LCBI (r = 0.30, P = 0.042) and annual LDL-cholesterol and triglyceride exposure were associated with higher SVG maxLCBI 4 mm (LDL-C: r = 0.41, P = 0.020; triglycerides: r = 0.36, P = 0.043). On multivariate analysis, the only independent predictor of SVG LCBI and maxLCBI 4mm was SVG age. SVG percutaneous coronary intervention was performed in 63% of the patients. An embolic protection device was used in 96% of SVG PCIs. Periprocedural myocardial infarction occurred in one patient., Conclusions: Older SVG age and greater lipid exposure are associated with higher SVG lipid burden. © 2016 Wiley Periodicals, Inc., (© 2016 Wiley Periodicals, Inc.)

Background: Coronary lipid core plaque may be associated with the incidence of subsequent cardiovascular events., Methods: We analyzed outcomes of 239 patients who underwent near-infrared spectroscopy (NIRS) coronary imaging between 2009-2011. Multivariable Cox regression was used to identify variables independently associated with the incidence of major adverse cardiovascular events (MACE; cardiac mortality, acute coronary syndromes (ACS), stroke, and unplanned revascularization) during follow-up., Results: Mean patient age was 64±9years, 99% were men, and 50% were diabetic, presenting with stable coronary artery disease (61%) or an acute coronary syndrome (ACS, 39%). Target vessel pre-stenting median lipid core burden index (LCBI) was 88 [interquartile range, IQR 50-130]. Median LCBI in non-target vessels was 57 [IQR 26-94]. Median follow-up was 5.3years. The 5-year MACE rate was 37.5% (cardiac mortality was 15.0%). On multivariable analysis the following variables were associated with MACE: diabetes mellitus, prior percutaneous coronary intervention performed at index angiography, and non-target vessel LCBI. Non-target vessel LCBI of 77 was determined using receiver-operating characteristic curve analysis to be a threshold for prediction of MACE in our cohort. The adjusted hazard ratio (HR) for non-target vessel LCBI ≥77 was 14.05 (95% confidence interval (CI) 2.47-133.51, p=0.002). The 5-year cumulative incidence of events in the above-threshold group was 58.0% vs. 13.1% in the below-threshold group., Conclusion: During long-term follow-up of patients who underwent NIRS imaging, high LCBI in a non-PCI target vessel was associated with increased incidence of MACE., (Published by Elsevier Inc.)

Objectives: We sought to determine the effect of age and sex on procedural outcomes and efficiency of chronic total occlusion (CTO) percutaneous coronary intervention (PCI)., Methods: We examined the clinical and angiographic characteristics and outcomes of 1675 CTO-PCIs performed in 1644 patients between 2012 and 2016 at 15 United States centers., Results: Mean age was 65.3 ± 10 years and 1408 (86%) were men. Overall technical and procedural success rates were 88% and 87%, respectively. Increasing age was associated with more comorbidities (dyslipidemia, hypertension, prior coronary artery bypass graft surgery, prior stroke, peripheral arterial disease, and chronic lung disease) and more lesion calcification. As compared with the reference age of <65 years, age >75 years was independently associated with technical failure (odds ratio [OR], 2.28; 95% confidence interval [CI], 1.20-4.28). Increasing age was also independently associated with the incidence of major adverse cardiovascular events (MACEs; OR, 2.93; 95% CI, 1.10-9.23 for 65-75 years and OR, 5.71; 95% CI, 1.89-19.60 for >75 years). Compared with men, women (n = 236; 14%) were older (66.8 ± 11.1 years vs 65.0 ± 9.8 years; P=.02), but had similar clinical characteristics and lower J-CTO scores (2.3 ± 1.3 vs 2.5 ± 1.2; P=.02). Although crude technical success rate was higher in women compared with men (92% vs 87%; P=.04), multivariable analysis did not show independent association between sex and technical failure (OR, men/women, 1.66; 95% CI, 0.86-3.50) or MACE (OR, 0.61; 95% CI, 0.25-1.73)., Conclusions: Older age, but not sex, is associated with lower technical success and higher in-hospital complication rate for CTO-PCI. CTO-PCI is relatively infrequently attempted in women, despite high technical success and acceptable complication rates.

Objectives: Although coronary chronic total occlusions (CTOs) are treated with percutaneous coronary intervention (PCI) to improve symptoms, studies demonstrating symptom improvement have been mostly limited to questionnaire responses. The current study assessed for changes in peak oxygen uptake during cardiopulmonary exercise testing after CTO-PCI., Methods: Patients with heart failure or angina symptoms referred for CTO-PCI were prospectively enrolled. The primary outcome of the study was improvement in peak oxygen uptake during cardiopulmonary exercise (CPX) testing 5 months after CTO-PCI. Secondary outcomes included improvement in physical capacity, angina, and self perception of health as assessed by questionnaires, and in plasma brain natriuretic peptide (BNP) levels., Results: CTO-PCI was attempted in 32 men (mean age, 62 ± 6 years; CTO vessel: 47% right coronary, 44% left anterior descending). CTO-PCI was unsuccessful in 1 patient, and 3 patients had restenosis of their CTO vessel at follow-up. In the 28 patients with patent CTO vessel at follow-up, significant improvements were noted in self-reported physical capacity, angina, and several aspects of health perception. In the 25 patients who underwent baseline and follow-up CPX testing, peak oxygen uptake significantly improved from 17.7 ± 4.3 mL/kg/min to 19.1 ± 4.0 mL/kg/min (P=.02). Plasma BNP levels significantly decreased from 143 ± 138 pg/mL to 102 ± 123 pg/mL (P=.01)., Conclusions: CTO-PCI in symptomatic patients was associated with improvements in cardiovascular exercise capacity, as assessed by peak oxygen uptake. These results suggest that in symptomatic patients with CTOs, PCI appears clinically beneficial.

Aims: The goal of this study was to describe the procedural characteristics, strategy selection and associated technical and efficiency outcomes for chronic total occlusion (CTO) percutaneous coronary intervention (PCI) of the right coronary artery (RCA)., Methods and Results: We examined the clinical and angiographic characteristics of patients who underwent RCA CTO PCI between 2012 and 2015 at 11 centres in the USA. The RCA was the CTO target vessel in 739 of 1,308 CTO PCIs (56%). Overall technical and procedural success rates were 90% and 88%, respectively. A major adverse cardiovascular event (MACE) occurred in 19 patients (2.6%). Technical success was most frequently achieved using antegrade wire escalation (38% of successful procedures) followed by retrograde (36%) and antegrade dissection/re-entry (26%). Technical success was similar between various locations of RCA CTOs (p=0.11). Compared with antegrade-only procedures, utilisation of any retrograde approach was associated with lower technical (85% vs. 95%, p<0.001) and procedural (82% vs. 94%, p<0.001) success and a higher MACE rate (3.8% vs. 1.4%, p=0.037)., Conclusions: RCA CTOs represent the majority of CTO target lesions, can be treated with high success and acceptable complication rates, and require frequent use of the retrograde approach and antegrade dissection/re-entry.

Objective: To examine the presence and localization of lipid-core plaque (LCP) in coronary vessels with chronic total occlusions (CTOs) using near-infrared spectroscopy (NIRS)., Methods: NIRS imaging was performed after guidewire crossing of the occlusion in 15 patients with CTOs. LCP was defined as ≥2 adjacent 2 mm yellow blocks on the block chemogram. We also measured the maximum lipid-core burden index (LCBI) in a 4 mm length of artery (maxLCBI4mm). Large LCP was defined as maxLCBI4mm ≥500., Results: Median patient age was 64 years (interquartile range [IQR], 61-67 years) and all patients were men with high prevalence of diabetes mellitus (64%) and prior coronary artery bypass graft surgery (27%). The CTO target vessel was the right coronary artery (46%), left anterior descending artery (27%), or circumflex artery (27%). Median occlusion length was 35 mm (IQR, 30-50 mm). LCP was present in 11 of 15 CTO vessels (73%) and a large LCP in 4 of 15 CTO vessels (27%). LCP was located at the proximal cap in 6 CTOs (55%), the CTO body in 6 CTOs (55%), and the distal cap in 2 CTOs (18%). The median overall LCBI and maxLCBI4mm were 145 (IQR, 79-243) and 415 (IQR, 267-505), respectively. All patients underwent successful stenting without any complications. The 12-month incidence of in-stent restenosis and target-lesion revascularization was 25%, and all patients who developed restenosis had an LCP at baseline., Conclusions: LCPs are commonly encountered in coronary CTO vessels, suggesting an active intraplaque atherosclerotic process. The impact of LCP on postintervention outcomes requires further study.

Objectives: We examined a contemporary, unselected cohort of patients with coronary chronic total occlusions (CTOs) to determine the impact of CTO revascularization on long-term outcomes., Methods: We retrospectively assessed the impact of CTO revascularization on clinical outcomes of consecutive patients found to have a CTO during coronary angiography performed at our institution during 2011 and 2012. The primary endpoint was the incidence of a major adverse cardiac event (MACE, defined as a composite of death, myocardial infarction, stroke, and target-vessel revascularization [TVR]). Survival analysis was performed in the overall and propensity-matched retrospective cohorts of patients stratified by prior coronary artery bypass graft (CABG) surgery. Propensity-adjusted hazard ratio (HR) and 95% confidence interval (95% CI) were calculated with Cox proportional hazards analysis. All analyses were by intention to treat., Results: Of 624 patients (319 without prior CABG and 305 with prior CABG) included in the present analysis, CTO revascularization (surgical or percutaneous) was attempted in 60% and 16% of patients without and with prior CABG, respectively. During a median follow-up of 26 months (range, 18-40 months), the incidence of MACE was 20.6%. CTO revascularization (achieved or attempted) was associated with lower incidence of MACE among patients without prior CABG (propensity-adjusted HR, 0.51; 95% CI, 0.27-0.94; P=.03), but not among prior CABG patients (propensity-adjusted HR, 1.38; 95% CI, 0.64-2.96; P=.41)., Conclusion: In a large, unselected patient population with coronary CTOs, a CTO revascularization attempt was associated with lower incidence of subsequent MACE among patients without prior CABG, but not among prior CABG patients.

Background: Various scoring systems have been developed to predict the technical outcome and procedural efficiency of chronic total occlusion (CTO) percutaneous coronary intervention (PCI)., Methods: We examined the predictive capacity of 3 CTO PCI scores (Clinical and Lesion-related [CL], Multicenter CTO registry in Japan [J-CTO] and Prospective Global Registry for the Study of Chronic Total Occlusion Intervention [PROGRESS CTO] scores) in 664 CTO PCIs performed between 2012 and 2016 at 13 US centers., Results: Technical success was 88% and the retrograde approach was utilized in 41%. Mean CL, J-CTO and PROGRESS CTO scores were 3.9±1.9, 2.6±1.2 and 1.4±1.0, respectively. All scores were inversely associated with technical success (p<0.001 for all) and had moderate discriminatory capacity (area under the curve 0.691 for the CL score, 0.682 for the J-CTO score and 0.647 for the PROGRESS CTO score [p=non-significant for pairwise comparisons]). The difference in technical success between the minimum and maximum CL score strata was the highest (32%, vs. 15% for J-CTO and 18% for PROGRESS CTO scores). All scores tended to perform better in antegrade-only procedures and correlated significantly with procedure time and fluoroscopy dose; the CL score also correlated significantly with contrast utilization., Conclusions: CL, J-CTO and PROGRESS CTO scores perform moderately in predicting technical outcome of CTO PCI, with better performance for antegrade-only procedures. All scores correlate with procedure time and fluoroscopy dose, and the CL score also correlates with contrast utilization., (Published by Elsevier Ireland Ltd.)

Background: We sought to determine the effect of lesion age on procedural techniques and outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI)., Methods: We examined the characteristics and outcomes of 394 CTO PCIs with data on lesion age, performed between 2012 and 2016 at 11 experienced US centres., Results: Mean patient age was 66 ± 10 years and 85.6% of the patients were men. Overall technical and procedural success rates were 90.1% and 87.5%, respectively. A major adverse cardiovascular event (MACE) occurred in 16 patients (4.1%). Mean and median lesion ages were 43 ± 62 months and 12 months (interquartile range, 3-64 months), respectively. Patients were stratified into tertiles according to lesion age (3-5, 5-36.3, and > 36.3 months). Older lesion age was associated with older patient age (68 ± 8 vs 65 ± 10 vs 64 ± 11 years; P = 0.009), previous coronary artery bypass grafting (62% vs 42% vs 30%; P < 0.001), and moderate/severe calcification (75% vs 53% vs 59%; P = 0.001). Older lesions more often required use of the retrograde approach and antegrade dissection/re-entry for successful lesion crossing. There was no difference in technical (87.8% vs 89.6% vs 93.0%; P = 0.37) or procedural (86.3% vs 87.4% vs 89.0%; P = 0.80) success, or the incidence of MACE (3.1% vs 3.0% vs 6.3%; P = 0.31) for older vs younger occlusions., Conclusions: Older CTO lesions exhibit angiographic complexity and more frequently necessitate the retrograde approach or antegrade dissection/re-entry. Older CTOs can be recanalized with high technical and procedural success and acceptable MACE rates. Lesion age appears unlikely to be a significant determinant of CTO PCI success., (Published by Elsevier Inc.)

Background: High success rates are achievable for chronic total occlusion (CTO) percutaneous coronary intervention (PCI) using the hybrid approach, but periprocedural complications remain of concern. Although scores estimating success and efficiency in CTO PCI have been developed, there is currently no available score for estimation of the risk for periprocedural complications. We sought to develop a scoring tool for prediction of periprocedural complications during CTO PCI., Methods and Results: We analyzed data from 1569 CTO PCIs in the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS CTO) using a derivation and validation sampling ratio of 2:1. Variables independently associated with periprocedural complications in multivariable analysis in the derivation set were assigned points based on their respective odds ratios. Forty-four (2.8%) patients experienced complications. Three factors were independent predictors of complications and were included in the score: patient age >65 years, +3 points (odds ratio, OR=4.85, CI 1.82-16.77); lesion length ≥23 mm, +2 points (OR=3.22, CI 1.08-13.89); and use of the retrograde approach +1 point (OR=2.41, CI 1.04-6.05). The resulting score showed good calibration and discriminatory capacity in the derivation (Hosmer-Lemeshow χ 2 6.271, P=0.281, receiver-operating characteristic [ROC] area=0.758) and validation (Hosmer-Lemeshow χ 2 4.551, P=0.473, ROC area=0.793) sets. Score values of 0 to 2, 3 to 4, and ≥5 were defined as low, intermediate, and high risk of complications (derivation cohort 0.4%, 1.8%, 6.5%, P<0.001; validation cohort 0.0%, 2.5%, 6.8%, P<0.001)., Conclusions: The PROGRESS CTO complication score is a useful tool for prediction of periprocedural complications in CTO PCI., Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02061436., (© 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)

Objectives: We sought to determine the impact of proximal cap ambiguity on procedural techniques and outcomes for coronary chronic total occlusion (CTO) percutaneous coronary intervention (PCI)., Methods: We examined the clinical and angiographic characteristics and outcomes of 1021 CTO-PCIs performed between 2012 and 2015 at 11 United States centers., Results: Proximal cap ambiguity was present in 31% of target lesions and was associated with increased clinical and angiographic complexity (prior coronary artery bypass graft surgery: 43% vs 33%; P=.01; moderate/severe calcification 66% vs 51%; P<.001) and lower technical success (85% vs 93%; P<.001) and procedural success (84% vs 91%; P=.01), but similar incidence of major adverse cardiac events (3.2% vs 2.9%; P=.77). A retrograde approach was more commonly utilized among cases with proximal cap ambiguity (68% vs 33%; P<.001), and was more likely to be the initial (39% vs 13%; P<.001) and successful approach (42% vs 20%; P<.001). Proximal cap ambiguity was associated with increased use of intravascular ultrasound (49% vs 36%; P=.01) and contrast (281 mL vs 250 mL; P<.001), higher air kerma radiation dose (4.0 Gy vs 3.0 Gy; P<.001), and longer procedure time (161 min vs 119 min; P<.001)., Conclusions: Proximal cap ambiguity is present in one-third of CTO-PCI target lesions and is associated with lower success rates, higher utilization of the retrograde approach, and lower procedural efficiency, but no significant difference in the incidence of major adverse cardiac events.

Background: Intravascular imaging can facilitate chronic total occlusion (CTO) percutaneous coronary intervention., Methods and Results: We examined the frequency of use and outcomes of intravascular imaging among 619 CTO percutaneous coronary interventions performed between 2012 and 2015 at 7 US centers. Mean age was 65.4±10 years and 85% of the patients were men. Intravascular imaging was used in 38%: intravascular ultrasound in 36%, optical coherence tomography in 3%, and both in 1.45%. Intravascular imaging was used for stent sizing (26.3%), stent optimization (38.0%), and CTO crossing (35.7%, antegrade in 27.9%, and retrograde in 7.8%). Intravascular imaging to facilitate crossing was used more frequently in lesions with proximal cap ambiguity (49% versus 26%, P<0.0001) and with retrograde as compared with antegrade-only cases (67% versus 31%, P<0.0001). Despite higher complexity (Japanese CTO score: 2.86±1.19 versus 2.43±1.19, P=0.001), cases in which imaging was used for crossing had similar technical and procedural success (92.8% versus 89.6%, P=0.302 and 90.1% versus 88.3%, P=0.588, respectively) and similar incidence of major cardiac adverse events (2.7% versus 3.2%, P=0.772). Use of intravascular imaging was associated with longer procedure (192 minutes [interquartile range 130, 255] versus 131 minutes [90, 192], P<0.0001) and fluoroscopy (71 minutes [44, 93] versus 39 minutes [25, 69], P<0.0001) time., Conclusions: Intravascular imaging is frequently performed during CTO percutaneous coronary intervention both for crossing and for stent selection/optimization. Despite its use in more complex lesion subsets, intravascular imaging was associated with similar rates of technical and procedural success for CTO percutaneous coronary intervention., Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02061436., (© 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)

Background: We sought to examine the efficacy and safety of chronic total occlusion percutaneous coronary intervention using the retrograde approach., Methods and Results: We compared the outcomes of the retrograde versus antegrade-only approach to chronic total occlusion percutaneous coronary intervention among 1301 procedures performed at 11 experienced US centers between 2012 and 2015. The mean age was 65.5±10 years, and 84% of the patients were men with a high prevalence of diabetes mellitus (45%) and previous coronary artery bypass graft surgery (34%). Overall technical and procedural success rates were 90% and 89%, respectively, and in-hospital major adverse cardiovascular events occurred in 31 patients (2.4%). The retrograde approach was used in 539 cases (41%), either as the initial strategy (46%) or after a failed antegrade attempt (54%). When compared with antegrade-only cases, retrograde cases were significantly more complex, both clinically (previous coronary artery bypass graft surgery prevalence, 48% versus 24%; P<0.001) and angiographically (mean Japan-chronic total occlusion score, 3.1±1.0 versus 2.1±1.2; P<0.001) and had lower technical success (85% versus 94%; P<0.001) and higher major adverse cardiovascular events (4.3% versus 1.1%; P<0.001) rates. On multivariable analysis, the presence of suitable collaterals, no smoking, no previous coronary artery bypass graft surgery, and left anterior descending artery target vessel were independently associated with technical success using the retrograde approach., Conclusions: The retrograde approach is commonly used in contemporary chronic total occlusion percutaneous coronary intervention, especially among more challenging lesions and patients. Although associated with lower success and higher major adverse cardiovascular event rates in comparison to antegrade-only crossing, retrograde percutaneous coronary intervention remains critical for achieving overall high success rates., (© 2016 American Heart Association, Inc.)

Background: The use of saphenous vein grafts (SVGs) for retrograde native-vessel chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study., Methods: We retrospectively reviewed the medical records and coronary angiograms of retrograde CTO-PCI performed through an SVG at four United States institutions between 2012 and 2013., Results: During the study period, retrograde CTO-PCI was performed in 144 of 572 cases (25.2%) and retrograde CTO-PCI via SVG in 21 patients (14.6% of all retrograde cases). Mean age was 71 ± 7 years and 95.2% of the patients were men. The CTO target vessel was the right coronary (38%), circumflex (38%), and left anterior descending (24%) artery. Mean J-CTO score was 3.5 ± 1.0. The most common reentry technique was reverse controlled antegrade dissection and reentry. Technical and procedural success rates were 86% and 81%, respectively, with retrograde SVG-PCI attempts being successful in 67%. A major adverse cardiac event occurred in 2 patients (1 periprocedural myocardial infarction and 1 tamponade resulting in death). Median contrast volume, fluoroscopy time, and procedure time were 250 mL, 91.6 minutes, and 214 minutes, respectively. Two SVGs were coiled due to competitive flow after CTO recanalization., Conclusion: Retrograde native-vessel CTO-PCI via SVG represents a small proportion of retrograde CTO-PCIs and was associated with high technical success rates, but may carry increased risk for complications.

We sought to examine the impact of previous failure on the outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We examined the clinical and angiographic characteristics and procedural outcomes of 1,213 consecutive patients who underwent 1,232 CTO PCIs from 2012 to 2015 at 12 US centers. Mean age was 65 ± 10 years, and 84.8% of patients were men. A previously failed attempt had been performed in 215 patients (17.5%). As compared with patients without previous CTO PCI failure, patients with previous failure had higher Multicenter CTO Registry in Japan CTO score (2.40 ± 1.13 vs 3.28 ± 1.29, p <0.0001) and were more likely to have in-stent restenosis (10.5% vs 28.4%, p <0.0001) and to undergo recanalization attempts using the retrograde approach (41% vs 50%, p = 0.011). Technical (90% vs 88%, p = 0.390) and procedural (89% vs 86%, p = 0.184) success were similar in the 2 study groups; however, median procedure time (125 vs 142 minutes, p = 0.026) and fluoroscopy time (45 vs 55 minutes, p = 0.015) were longer in the previous failure group. In conclusion, a previously failed CTO PCI attempt is associated with higher angiographic complexity, longer procedural duration, and fluoroscopy time, but not with the success and complication rates of subsequent CTO PCI attempts., (Published by Elsevier Inc.)