Search

The impact of diabetes mellitus (DM) on the outcomes of bifurcation percutaneous coronary intervention (PCI) has received limited study. We compared the procedural characteristics and outcomes of patients with and without diabetes mellitus among 1,302 bifurcation PCIs (1,147 patients) performed at five centers between 2013-2024. The prevalence of diabetes mellitus was 33.8% (n=388). Patients with diabetes were younger, had more cardiovascular risk factors and higher angiographic complexity, including more main vessel calcification and more frequent stenoses in the left main, proximal left anterior descending and right coronary artery. There was no difference in technical (95.5% vs 94.9%, p = 0.613) or procedural success (90.2% vs 91.3%, p = 0.540); provisional stenting was used less frequently in diabetic patients (64.5% vs 71.1%, p = 0.015). Diabetic patients had higher rates of repeat in-hospital PCI and acute kidney injury. Other in-hospital outcomes were similar after adjusting for confounders. During a median follow-up of 1,095 days diabetes was independently associated with higher incidence of major adverse cardiovascular events (hazard ratio [HR]: 2.04, 95% confidence intervals [CI]: 1.52, 2.72, p < 0.001), myocardial infarction (HR: 1.94, 95% CI: 1.05, 3.25, p = 0.033), death (HR: 2.26, 95% CI: 1.46, 3.51, p < 0.001), target (HR: 1.6, 95% CI: 1.01, 2.66, p = 0.045) and non-target (HR: 2.00, CI: 1.06, 3.78, p = 0.032) vessel revascularization. Compared with non-diabetics, patients with diabetes mellitus undergoing bifurcation PCI had higher risk of in-hospital repeat-PCI and major adverse cardiac events during follow-up. Diabetes mellitus (DM) increases the risk of coronary artery disease (CAD) and has been associated with more complex and multifocal coronary lesions (1,2). Percutaneous coronary intervention (PCI) in diabetic patients has been associated with high short- and long-term incidence of adverse events in some (3) but not all (4,5) studies. In a study by Xue et al. newly diagnosed and previously known diabetes patients undergoing PCI had higher incidence of follow-up major adverse cardiac events (MACE) rates compared with non-diabetics (6). Bifurcation lesions account for 15-20% of all PCIs and can be challenging to perform (7-9). Bifurcation PCI has been associated with lower technical and procedural success (10) and higher adverse outcomes (11,12). While there are published data on the impact of diabetes mellitus in patients undergoing PCI (13), there is limited data on its impact on bifurcation PCI (Table 1). We examined the impact of diabetes mellitus on the outcomes of bifurcation PCI in a multicenter registry., Competing Interests: Declaration of competing interest Dr. Brilakis: consulting/speaker honoraria from Abbott Vascular, American Heart Association (associate editor Circulation), Biotronik, Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), CSI, Elsevier, GE Healthcare, IMDS, Medtronic, and Teleflex; research support: Boston Scientific, GE Healthcare; owner, Hippocrates LLC; shareholder: MHI Ventures, Cleerly Health, Stallion Medical. The rest of the authors have no relevant disclosures., (Copyright © 2024. Published by Elsevier Inc.)

Background: There is limited comparative data on the use of plaque modification devices during chronic total occlusion (CTO) percutaneous coronary intervention (PCI)., Methods: We compared intravascular lithotripsy (IVL) with rotational atherectomy (RA) for lesion preparation in patients who underwent CTO PCI across 50 US and non-US centers from 2019 to 2024., Results: Among 15,690 patients who underwent CTO PCI during the study period, 436 (2.78%) underwent IVL and 381 (2.45%) RA. Patients treated with IVL had more comorbidities and more complex CTO lesions. Antegrade wiring was the most commonly used initial and successful crossing strategy for lesions treated with both IVL and RA, although the retrograde approach was more frequently employed in IVL cases. Procedure and fluoroscopy times, as well as air kerma radiation doses and contrast volumes, were higher in patients treated with RA compared with IVL. There were no significant differences between the groups in technical success (97.2% vs. 95.3%, p=0.20), procedural success (94.7% vs. 91.8%, p=0.14), and in-hospital major adverse cardiac events (MACE) (3.0 % vs. 4.2%, p=0.47). However, coronary perforations were more frequent in patients undergoing RA (9.5% vs. 3.2%, p<0.001). Multivariable logistic regression analysis revealed that IVL compared with RA was not independently associated with technical success, procedural success, or in-hospital MACE., Conclusions: In patients undergoing CTO PCI, IVL is associated with similar in-hospital MACE, technical success, and procedural success, but lower incidence of coronary perforation, compared with RA., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Brilakis reports administrative support was provided by Minneapolis Heart Institute Foundation. Brilakis reports a relationship with Abbott Vascular Inc that includes: consulting or advisory. Jaffer reports a relationship with Shockwave Medical Inc that includes: funding grants. Azzalini reports a relationship with Shockwave Medical Inc that includes: consulting or advisory. Dr. Jaffer: –sponsored research: Canon, Siemens, Shockwave, Teleflex, Boston Scientific, HeartFlow, Neovasc; consultant/speakers fees: Magenta Medical, Philips, Biotronik, Mercator, Terumo, Abiomed, Shockwave, DurVena, Intravascular Imaging Inc., Medtronic, FastWave; Equity interest: Intravascular Imaging Inc, DurVena, FastWave. Massachusetts General Hospital – licensing arrangements: Terumo, Canon, SpectraWAVE, for which FAJ has the right to receive royalties. Dr. Azzalini received consulting fees from Teleflex, Abiomed, GE Healthcare, Reflow Medical, Shockwave, and Cardiovascular Systems, Inc.; received a research grant by Abiomed; serves on the advisory board of Abiomed and GE Healthcare; and owns equity in Reflow Medical. Dr. Davies: speaking honoraria from Abiomed, Asahi Intec, Boston Sci, Medtronic, Shockwave and Teleflex. Also serves on advisory boards for Abiomed, Avinger, Boston Sci, Medtronic, Rampart and Shockwave. Dr. Sandoval: consulting/speaker honoraria from Abbott Diagnostics, Roche Diagnostics, Zoll, Philips. JACC Advances associate editor. Patent 20210401347. Dr. Brilakis: consulting/speaker honoraria from Abbott Vascular, American Heart Association (associate editor Circulation), Biotronik, Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), CSI, Elsevier, GE Healthcare, IMDS, Medtronic, and Teleflex; research support: Boston Scientific, GE Healthcare; owner, Hippocrates LLC; shareholder: MHI Ventures, Cleerly Health, Stallion Medical. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Inc.)

Background: There is limited information about the frequency and outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in anomalous coronary arteries (ACA)., Methods: We examined the clinical and angiographic characteristics and procedural outcomes of CTO PCI in ACA among 14,173 patients who underwent 14,470 CTO PCIs at 46 US and non-US centers between 2012 and 2023., Results: Of 14,470 CTO PCIs, 36 (0.24%) were CTO PCIs in an ACA. ACA patients had similar baseline characteristics as those without an ACA. The type of ACA in which the CTO lesion was found were as follows: anomalous origin of the right coronary artery (ARCA) (17, 48.5%), anomalous origin of left circumflex coronary artery (9, 25.7%), left anterior descending artery and left circumflex artery with separate origins (4, 11.4%), anomalous origin of the left anterior descending artery (2, 5.7%), dual left anterior descending artery (2, 5.7%) and woven coronary artery 1 (2.8%). The Japan CTO score was similar between both groups (2.17 ± 1.32 vs 2.38 ± 1.26, p = 0.30). The target CTO in ACA patients was more likely to have moderate/severe tortuosity (44% vs 28%, p = 0.035), required more often use of retrograde approach (27% vs 12%, p = 0.028), and was associated with longer procedure (142.5 min vs 112.00 min [74.0, 164.0], p = 0.028) and fluoroscopy (56 min [40, 79 ml] vs 42 min [25, 67], p = 0.014) time and higher contrast volume (260 ml [190, 450] vs 200 ml [150, 300], p = 0.004) but had similar procedural (91.4% vs 85.6%, p = 0.46) and technical (91.4% vs 87.0%, p = 0.59) success. No major adverse cardiac events (MACE) were seen in ACA patients (0% [0] vs 1.9% [281] in non-ACA patients, p = 1.00). Two coronary perforations were reported in ACA CTO PCI (p = 0.7 vs. non-ACA CTO PCI)., Conclusions: CTO PCI of ACA comprise 0.24% of all CTO PCIs performed in the PROGRESS CTO registry and was associated with higher procedural complexity but similar technical and procedural success rates and similar MACE compared with non-ACA CTO PCI., (© 2024 Wiley Periodicals LLC.)

Ranolazine is an anti-anginal medication given to patients with chronic angina and persistent symptoms despite medical therapy. We examined 11 491 chronic total occlusion (CTO) percutaneous coronary interventions (PCI) that were performed at 41 US and non-US centers between 2012 and 2023 in the PROGRESS-CTO Registry. Patients on ranolazine at baseline had more comorbidities, more complex lesions, lower procedural and technical success (based on univariable but not multivariable analysis), and higher incidence of major adverse cardiac events (MACE) (on both univariable and multivariable analysis).

Background: There is variability in clinical and lesion characteristics as well as techniques in chronic total occlusion (CTO) percutaneous coronary intervention (PCI)., Methods: We analyzed patient and lesion characteristics, techniques, and outcomes in 11 503 CTO-PCI procedures performed in North America (NA) and in the combined regions of Europe, Asia, and Africa from 2017 to 2023 as documented in the PROGRESS-CTO registry., Results: Eight thousand four hundred seventy-nine (74%) procedures were performed in NA. Compared with non-NA patients, NA patients were older, with higher body mass index and higher prevalence of diabetes, hypertension, dyslipidemia, family history of coronary artery disease, prior history of PCI, coronary artery bypass graft surgery and heart failure, cerebrovascular disease, and peripheral arterial disease. Their CTOs were more complex, with higher J-CTO (2.56 ± 1.22 vs 1.81 ± 1.24; P less than .001) and PROGRESS-CTO (1.29 ± 1.01 vs 1.07 ± 0.95; P less than .001) scores, longer length, and higher prevalence of proximal cap ambiguity, blunt/no stump, moderate to severe calcification, and proximal tortuosity. Retrograde (31.0% vs 22.1%; P less than .001) and antegrade dissection and re-entry (ADR) (21.2% vs 9.2%; P less than .001) were more commonly used in NA centers, along with intravascular ultrasound (69.0% vs 10.1%; P less than .001). Procedure and fluoroscopy times were longer in NA, while contrast volume and radiation dose were lower. Technical (86.7% vs 86.8%; P > .90) and procedural (85.4% vs 85.8%; P = .70) success and in-hospital major adverse cardiovascular events (MACE) (1.9% vs 1.7%; P = .40) were similar in NA and non-NA centers., Conclusions: Compared with non-NA patients, NA patients undergoing CTO PCI have more comorbidities, higher CTO lesion complexity, are more likely to undergo treatment with retrograde and ADR, and have similar technical success and MACE.

Background: The impact of peripheral artery disease (PAD) on the outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is not well studied., Methods: We analyzed the association of PAD with CTO-PCI outcomes using data from the PROGRESS-CTO registry of procedures performed at 47 centers between 2012 and 2023., Results: The prevalence of PAD among 12 961 patients who underwent CTO PCI during the study period was 13.9% (1802). PAD patients were older, more likely to be current smokers, and had higher rates of dyslipidemia, diabetes, cerebrovascular disease, hypertension, prior myocardial infarction, PCI, and coronary artery bypass graft surgery. Their PROGRESS-CTO (1.35 vs 1.22; P < .001) and J-CTO (2.63 vs 2.33; P < .001) scores were higher, lesion length was longer, and angiographic characteristics were more complex. Their access site was more likely to be bifemoral (33.6% vs 30.9%; P = .024) compared with patients with no PAD. Technical (82.9% vs 87.7%; P < .001) and procedural (80.5% vs 86.6%; P < .001) success rates were lower in patients with PAD, while the incidence of major adverse cardiovascular events (MACE) was higher (3.1% vs 1.8%; P < .001), with higher mortality (0.8% vs 0.4%; P = .034), acute myocardial infarction rate (0.9% vs 0.4%; P = .010), and perforations rate (6.6% vs 4.5%; P < .001). In multivariable analysis, PAD was associated with higher MACE (odds ratio [OR]: 1.53; 95% CI, 1.01-2.26; P = .038) and lower technical success (OR: 0.82; 95% CI, 0.69-0.99; P = .039)., Conclusions: PAD patients undergoing CTO PCI have higher comorbidity burden, more complex CTOs, higher MACE, and lower technical success.

Background: There is limited data on predicting successful chronic total occlusion crossing using primary antegrade wiring (AW)., Objectives: The aim of this study was to develop and validate a machine learning (ML) prognostic model for successful chronic total occlusion crossing using primary AW., Methods: We used data from 12,136 primary AW cases performed between 2012 and 2023 at 48 centers in the PROGRESS CTO registry (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention; NCT02061436) to develop 5 ML models. Hyperparameter tuning was performed for the model with the best performance, and the SHAP (SHapley Additive exPlanations) explainer was implemented to estimate feature importance., Results: Primary AW was successful in 6,965 cases (57.4%). Extreme gradient boosting was the best performing ML model with an average area under the receiver-operating characteristic curve of 0.775 (± 0.010). After hyperparameter tuning, the average area under the receiver-operating characteristic curve of the extreme gradient boosting model was 0.782 in the training set and 0.780 in the testing set. Among the factors examined, occlusion length had the most significant impact on predicting successful primary AW crossing followed by blunt/no stump, presence of interventional collaterals, vessel diameter, and proximal cap ambiguity. In contrast, aorto-ostial lesion location had the least impact on the outcome. A web-based application for predicting successful primary AW wiring crossing is available online (PROGRESS-CTO website) (https://www.progresscto.org/predict-aw-success)., Conclusions: We developed an ML model with 14 features and high predictive capacity for successful primary AW in chronic total occlusion percutaneous coronary intervention., Competing Interests: Funding Support and Author Disclosures Dr Choi serves on the Advisory Board of 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 Intec, Boston Sci, Medtronic, Shockwave, and Teleflex; and serves on the Advisory Boards of Abiomed, Avinger, Boston Scientific, Medtronic, and Rampart. Dr Jaffer has performed sponsored research for Canon, Siemens, Shockwave, Teleflex, Mercator, and Boston Scientific; has serves as a consultant for Boston Scientific, Siemens, Magenta Medical, IMDS, Asahi Intecc, Biotronik, Philips, and Intravascular Imaging Inc; has equity interest in Intravascular Imaging Inc and DurVena; and has the right to receive royalties through Massachusetts General Hospital licensing arrangements with Terumo, Canon, and Spectrawave. Dr Jaber has received fees from Medtronic; and has received proctoring fees from Abbott. Dr Rinfret has received fees from Abbott Vascular, Abiomed, Boston Scientific, and SoundBite Medical; and has served as a consultant for Teleflex. Dr Nicholson has served as a proctor for Abbott Vascular, Boston Scientific, and Asahi Intecc; has served on the Speakers Bureau and Advisory Boards of 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, Abbott Vascular, Reflow Medical, and Cardiovascular Systems, Inc; serves on the Advisory Boards of Abiomed and GE Healthcare; and owns equity in Reflow Medical. Dr Kearney has received consulting fees or honoraria from Asahi Intecc, Abiomed, Boston Scientific, Philips, Medtronic, Teleflex, and Reflow Medical. Dr Alaswad has served as a consultant and speaker for Boston Scientific, Abbott Cardiovascular, Teleflex, and CSI. 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 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), CSI, 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 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 © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: The aim of this study was to evaluate the impact of prolonged dual antiplatelet therapy (DAPT) on clinical outcomes in patients undergoing percutaneous coronary interventions (PCI) for bifurcation coronary lesions., Methods: A total of 1000 patients who underwent PCI for coronary bifurcation lesions and had clinical follow-up were divided into two groups based on the duration of DAPT: DAPT > 12 months and DAPT ≤ 12 months). Patients who experienced a myocardial infarction, required repeat PCI, or died within 1 year after the initial procedure were excluded., Results: Among the 1000 eligible patients, 394 patients received DAPT for > 12 months (39.4%). Most patients in our study presented with chronic coronary disease (61%). The majority of patients in our study (62.8%) had a low bleeding risk. The median follow-up duration was 35 months (interquartile range 20.6-36.5). There were no significant differences in the major adverse cardiovascular events (MACE) between groups of prolonged DAPT (> 12 month) and DAPT ≤ 12 months (18.8% vs. 14.9%, p = 0.11). Patients with clinical features of high ischemic risk (HIR) had a significantly increased risk of MACE (hazard ratio [HR] 1.92, 95% confidence interval [CI] 1.12-3.26, p = 0.015) when compared with patients without clinical features of HIR. Compared with DAPT ≤ 12 months, extended DAPT (> 12 months) did not improve outcomes in patients with clinical (HR 1.24, 95% CI 0.90-1.72, p = 0.19) and technical features (HR 1.04, 95% CI 0.67-1.63, p = 0.85) of HIR., Conclusion: In this multicenter real-world registry, administration of DAPT for more than 12 months in patients who have undergone PCI for bifurcation lesion is not associated with a reduced incidence of MACE in long-term follow-up., Registration: ClinicalTrials.gov identifier no. NCT03450577., (© 2024. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Background: Antegrade wiring is the most commonly used chronic total occlusion (CTO) crossing technique., Methods: Using data from the PROGRESS CTO registry (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention; Clinicaltrials.gov identifier: NCT02061436), we examined the clinical and angiographic characteristics and procedural outcomes of CTO percutaneous coronary interventions (PCIs) performed using a primary antegrade wiring strategy., Results: Of the 13 563 CTO PCIs performed at 46 centers between 2012 and 2023, a primary antegrade wiring strategy was used in 11 332 (83.6%). Upon multivariable logistic regression analysis, proximal cap ambiguity (odds ratio [OR]: 0.52; 95% CI, 0.46-0.59), side branch at the proximal cap (OR: 0.85; 95% CI, 0.77-0.95), blunt/no stump (OR: 0.52; 95% CI: 0.47-0.59), increasing lesion length (OR [per 10 mm increase]: 0.79; 95% CI, 0.76-0.81), moderate to severe calcification (OR: 0.73; 95% CI, 0.66-0.81), moderate to severe proximal tortuosity (OR: 0.67; 95% CI, 0.59-0.75), bifurcation at the distal cap (OR: 0.66; 95% CI, 0.59-0.73), left anterior descending artery CTO (OR [vs right coronary artery]: 1.44; 95% CI, 1.28-1.62) and left circumflex CTO (OR [vs right coronary artery]: 1.22; 95% CI, 1.07-1.40), non-in-stent restenosis lesion (OR: 0.56; 95% CI, 0.49-0.65), and good distal landing zone (OR: 1.18; 95% CI, 1.06-1.32) were independently associated with primary antegrade wiring crossing success., Conclusions: The use of antegrade wiring as the initial strategy was high (83.6%) in our registry. We identified several parameters associated with primary antegrade wiring success.

Background: The complex high-risk indicated percutaneous coronary intervention (CHIP) score is a tool developed using the British Cardiovascular Intervention Society (BCIS) database to define CHIP cases and predict in-hospital major adverse cardiac or cerebrovascular events (MACCE)., Aim: To assess the validity of the CHIP score in chronic total occlusion (CTO) percutaneous coronary intervention (PCI)., Methods: We evaluated the performance of the CHIP score on 8341 CTO PCIs from the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO) performed at 44 centers between 2012 and 2023., Results: In our cohort, 7.8% (n = 647) of patients had a CHIP score of 0, 50.2% (n = 4192) had a CHIP score of 1-2, 26.2% (n = 2187) had a CHIP score of 3-4, 11.7% (n = 972) had a CHIP score of 5-6, 3.3% (n = 276) had a CHIP score of 7-8, and 0.8% (n = 67) had a CHIP score of 9+. The incidence of MACCE for a CHIP score of 0 was 0.6%, reaching as high as 8.7% for a CHIP score of 9+, confirming that a higher CHIP score is associated with a higher risk of MACCE. The estimated increase in the risk of MACCE per one score unit increase was 100% (95% confidence interval [CI]: 65%-141%). The AUC of the CHIP score model for predicting MACCE in our cohort was 0.63 (95% CI: 0.58-0.67). There was a positive correlation between the CHIP score and the PROGRESS-CTO MACE score (Spearman's correlation: 0.37; 95% CI: 0.35-0.39; p < 0.001)., Conclusions: The CHIP score has modest predictive capacity for MACCE in CTO PCI., (© 2024 Wiley Periodicals LLC.)

Background: There is limited data on equipment loss or entrapment during chronic total occlusion (CTO) percutaneous coronary intervention (PCI)., Methods: We analyzed the baseline clinical and angiographic characteristics and outcomes of equipment loss/entrapment at 43 US and non-US centers between 2017 and 2023., Results: Equipment loss/entrapment was reported in 40 (0.4%) of 10 719 cases during the study period. These included guidewire entrapment/fracture (n = 21), microcatheter entrapment/fracture (n = 11), stent loss (n = 8) and balloon entrapment/fracture/rupture (n = 5). The equipment loss/entrapment cases were more likely to have moderate to severe calcification, longer lesion length, higher J-CTO and PROGRESS-CTO complications scores, and use of the retrograde approach compared with the remaining cases. Retrieval was attempted in 71.4% of the guidewire, 90.9% of the microcatheter, 100% of the stent loss, and 100% of the balloon cases, and was successful in 26.7%, 30.0%, 50%, and 40% of the cases, respectively. Procedures complicated by equipment loss/entrapment had higher procedure and fluoroscopy time, contrast volume and patient air kerma radiation dose, lower procedural (60.0% vs 85.6%, P less than .001) and technical (75.0% vs 86.8%, P = .05) success, and higher incidence of major adverse cardiac events (MACE) (17.5% vs 1.8%, P less than .001), acute MI (7.5% vs 0.4%, P less than .001), emergency coronary artery bypass graft (CABG) (2.5% vs 0.1%, P = .03), perforation (20.0% vs 4.9%, P less than .001), and death (7.5% vs 0.4%, P less than .001)., Conclusions: Equipment loss is a rare complication of CTO PCI; it is more common in complex CTOs and is associated with lower technical success and higher MACE.

There is significant variation in wire utilization patterns for chronic total occlusion (CTO) percutaneous coronary intervention. This study aimed to compare the outcomes of polymer-jacketed wires (PJWs) versus non-PJWs in anterograde procedures. We analyzed clinical and angiographic characteristics, and procedural outcomes of 7,575 anterograde CTO percutaneous coronary interventions that were performed at 47 centers between 2012 and 2023. Cases in which PJWs were exclusively used were classified in the PJW group, whereas cases where at least one non-PJW was employed were classified in the non-PJW group. Study end points were as follows: technical success, coronary perforation, major adverse cardiac event. PJWs were exclusively used in 3,481 cases (46.0%). These cases had lower prevalence of proximal cap ambiguity, blunt stump, and moderate/severe calcification. They also had lower Japanese CTO (J-CTO), Prospective Global Registry for the Study of Chronic Total Occlusion (PROGRESS-CTO), and PROGRESS-CTO complications scores, higher technical success (94.3% vs 85.7%, p <0.001), and lower perforation rates (2.2% vs 3.2%, p = 0.013). Major adverse cardiac event rates did not differ between groups (1.3% vs 1.5%, p = 0.53). Exclusive use of PJWs was independently associated with higher technical success in both the multivariable (odds ratio [OR] 2.66, 95% confidence interval [CI] 2.13 to 3.36, p <0.001) and inverse probability of treatment weight analysis (OR 2.43, 95% CI 2.04 to 2.89, p <0.001). Exclusive use of PJWs was associated with lower risk of perforation in the multivariable analysis (OR 0.69, 95% CI 0.49 to 0.95, p = 0.02), and showed a similar trend in the inverse probability of treatment weight analysis (OR 0.77, 95% CI 0.57 to 1.04, p = 0.09). Exclusive use of PJWs is associated with higher technical success and lower perforation risk in this non-randomized series of patients., Competing Interests: Declaration of competing interest The authors have no competing interests to declare., (Copyright © 2024 Elsevier Inc. All rights reserved.)