BACKGROUND:Epicardial collaterals represent a conduit for retrograde crossing in chronic total occlusion (CTO) percutaneous coronary intervention (PCI), but carry higher procedural risk compared with septal or bypass graft crossing. METHODS:We analyzed 1527 CTO PCI cases attempted via epicardial collaterals between January 2012 and March 2026 from the PROGRESS-CTO multicenter registry (49 centers). Temporal trends were assessed using logistic regression. Technical success, procedural success, and in-hospital major adverse cardiac events (MACE) were evaluated. RESULTS:Mean patient age was 65 ± 10 years; 86.4% were men. Lesion complexity was high (mean J-CTO score 3.16 ± 1.02). Use of the retrograde approach overall and via epicardial collaterals decreased significantly over time (both p < 0.001). Epicardial collateral crossing success increased (p < 0.001), while MACE rates did not change significantly (p = 0.085). Technical and procedural success were 77.0% and 74.4%, respectively. In-hospital MACE occurred in 3.8% of cases. Coronary perforation occurred in 13.8% of procedures and was strongly associated with MACE (15.2% vs. 2.0%, p < 0.001). CONCLUSIONS:In a large contemporary multicenter registry, while use of retrograde CTO PCI via epicardial collaterals declined over time, crossing success improved without a significant increase in complications, suggesting improved case selection and procedural expertise.
BACKGROUND:Ulnar artery access may provide an alternative access route for chronic total occlusion percutaneous coronary intervention (CTO PCI), but data is limited. AIMS:To assess the utilization, patient characteristics, and in-hospital outcomes of ulnar artery access compared with radial access and non-ulnar access in patients undergoing CTO PCI. METHODS:We analyzed patients who underwent CTO PCI between 2012 and 2024 at 51 centers within the PROGRESS-CTO Registry. Patients were stratified by access: (1) no radial/ulnar, (2) radial without ulnar, and (3) ulnar. The primary endpoint was in-hospital major adverse cardiovascular events (MACE). Secondary endpoints included technical success. Multivariable logistic regression was used to identify independent predictors of outcomes. RESULTS:Among 18,826 patients, 8844 (47.0%) had no radial/ulnar access, 9835 (52.2%) radial without ulnar, and 147 (0.8%) ulnar. Ulnar patients were younger (62.5 ± 10.4 vs. 64.0 ± 10.4 radial and ulnar, 65.1 ± 10.5 no radial/ulnar, p < 0.001) and had higher prevalence of prior PCI (73.6% vs. 59.3% and 64.0%, p < 0.001) and peripheral arterial disease (23.9% vs. 12.1% and 15.1%, p < 0.001). Lesion complexity was lower with ulnar access (J-CTO 2.19 ± 1.27 vs. 2.32 ± 1.27 radial and 2.47 ± 1.21 no radial/ulnar, p < 0.001). In-hospital outcomes were similar: MACE (2.7% ulnar vs. 1.8% radial vs. 2.0% no radial/ulnar, p = 0.315), technical success (83.7% vs. 87.3% vs. 87.2%, p = 0.425), and access complications (0.7% vs. 0.7% vs. 1.2%, p = 0.001). Logistic regression showed no independent association between ulnar access and MACE, technical success, or access-site complications. CONCLUSION:In the largest series to date, ulnar access was used in 0.8% of CTO PCI with similar outcomes to radial and femoral access. Given its use in lower complexity cases, these findings are hypothesis-generating and warrant prospective evaluation.
There are limited comparative data on the use of plaque modification devices during chronic total occlusion (CTO) percutaneous coronary intervention (PCI). 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. Of 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 co-morbidities and more complex CTO lesions. Antegrade wiring was the most used initial and successful crossing strategy for lesions treated with both IVL and RA, although the retrograde approach was more frequently used in IVL cases. Procedure and fluoroscopy times, and air kerma radiation doses and contrast volumes, were greater in patients treated with RA than those treated 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 (MACEs) (3.0% vs 4.2%, p = 0.47). However, coronary artery perforations were more frequent in patients who underwent 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. In patients who undergo CTO PCI, IVL is associated with similar in-hospital MACE, technical success, and procedural success but lower incidence of coronary artery perforation compared with RA.
OBJECTIVES:The impact of contrast type in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) remains controversial. The authors sought to evaluate the impact of contrast medium selection on patients undergoing CTO PCI. METHODS:The authors examined the outcomes of patients who underwent CTO PCI using iso-osmolar (iodixanol) vs pooled low-osmolar contrast media (LOCM) using data from the PROGRESS-CTO registry. RESULTS:Iodixanol was used in 1007 (18.1%) of 5558 CTO PCIs. Compared with pooled LOCM, iodixanol-treated patients were more likely to be women, were older, and more likely to have diabetes, dyslipidemia, hypertension, history of heart failure, myocardial infarction, coronary artery bypass graft surgery, and stroke. Iodixanol cases had higher complexity, with longer lesion length (35.25 ± 25.16 vs 28.91 ± 19.46 mm, P less than .001), higher prevalence of moderate or severe calcification (43% vs 37%, P less than .001) and moderate or severe proximal tortuosity (30% vs 24%, P less than .001), and higher Japanese-CTO (2.52 vs 2.17, P less than .001) and PROGRESS-CTO scores (1.30 vs 1.16, P less than .001). Iodixanol cases required longer procedure times but similar contrast volumes. Technical (85.3% vs 89.2%, P = .001) and procedural success (83.4% vs 87.3%, P = .001) were lower in iodixanol cases. Acute kidney injury (AKI) occurred in 6.4% of cases. After propensity score matching, the patients who received iodixanol had lower incidence of AKI (odds ratio [OR]: 0.67; 95% CI, 0.47, 0.97; P = .032) and a trend for lower incidence of major adverse renal or cardiovascular events (OR: 0.75; 95% CI, 0.56, 1.0; P = .061). CONCLUSIONS:AKI occurred in approximately 6% of CTO PCI cases. Iodixanol use was associated with a lower incidence of AKI, despite being used in more complex patients.
BACKGROUND:CTO-ARC (Chronic Total Occlusion Academic Research Consortium) defines CTO modification procedures (previously called investment procedures) as intentional balloon dilatation (diameter ≥ 2.0 mm) of the entire CTO, including the proximal and distal caps and the CTO body. AIMS:The aim of this study is to compare the outcomes of repeat CTO PCI between patients who underwent lesion modification during the initial failed procedure and those who did not. METHODS:We analyzed the association of CTO modification with the baseline clinical and angiographic characteristics and outcomes of 2829 patients, with a total of 2869 CTOs who underwent CTO percutaneous coronary intervention (PCI) after a previously failed attempt. RESULTS:CTO modification was performed in 600 of 2869 CTOs (20.9%) that underwent a repeat PCI attempt. CTOs that underwent modification had a higher prevalence of blunt/no stump (63.9% vs. 54.5%, p < 0.001), moderate/severe calcification (59.4% vs. 48.5%, p < 0.001), and moderate/severe proximal tortuosity (43.6% vs. 30.4%, p < 0.001). They also had longer length (38 vs. 31 mm, p < 0.001) and higher J-CTO (3.69 vs. 3.21, p < 0.001) score. There was no statistically significant difference in technical (84.1% vs. 85.4%, p = 0.478) or procedural (82.7% vs. 84.2%, p = 0.403) success or major adverse cardiac events (MACE, 1.7% vs. 1.8%, p = 1.0) between the modification and no modification groups. Similarly, among patients who underwent CTO modification, there were no significant differences in outcomes between early ( < 60 days) and late ( ≥ 60 days) reattempts after the initial failure. Technical success was significantly higher after subintimal tracking and re-entry (STAR) than subintimal plaque modification (SPM) (82.5% vs. 60.0%, p = 0.028). CONCLUSIONS:CTO modification procedures were performed in approximately one of five CTO PCIs during the initial failed procedure. During reattempt CTO PCI, despite higher lesion complexity, CTO modification was associated with similar technical and procedural success and MACE compared to patients undergoing reattempt CTO PCI without prior CTO modification. Among modification techniques, STAR was associated with higher technical and procedural success than SPM.
