Sevket Gorgulu

Background: The optimal revascularization strategy for isolated left anterior descending artery chronic total occlusion (CTO) remains uncertain, with limited comparative data between CTO percutaneous coronary intervention (CTO‐PCI) and coronary artery bypass grafting (CABG). Methods: The RITUAL (Revascularization of Isolated Chronic Total Occlusion of the Left Anterior Descending Artery) study was a retrospective, multicenter analysis conducted at 4 centers including patients who underwent revascularization for isolated left anterior descending artery CTO between January 2017 and January 2023. Lesion complexity was assessed using the Japanese Chronic Total Occlusion score. The primary end point was technical and procedural success. Secondary end points included 3‐year major adverse cardiac and cerebrovascular events and a periprocedural composite safety outcome. Multivariable Cox regression and restricted cubic spline analyses were performed. Results: Among 2382 patients treated with CTO‐PCI and 5850 surgical patients screened, 297 eligible patients (184 CTO‐PCI, 113 CABG) were analyzed. Baseline characteristics were comparable. Adjusted procedural success favored CTO‐PCI (88.6% versus 83.2%; adjusted hazard ratio [HR], 1.33 [95% CI, 1.01–1.75]; P =0.043), while technical success was similar. CABG was associated with higher rates of acute kidney injury and blood transfusion. At 3 years, all‐cause death and major adverse cardiac and cerebrovascular events were comparable. However, adjusted periprocedural composite safety outcomes were lower with CTO‐PCI (20.7% versus 35.4%; adjusted HR, 0.63 [95% CI, 0.40–0.99]; P =0.047). Increasing Japanese Chronic Total Occlusion score was linearly associated with higher major adverse cardiac and cerebrovascular event risk ( P =0.007), and among patients with a Japanese Chronic Total Occlusion score <3, periprocedural composite safety outcomes favored CTO‐PCI. Conclusions: In isolated left anterior descending artery CTO, no significant differences in 3‐year clinical outcomes were observed between CABG and CTO‐PCI, although CABG was associated with higher in‐hospital complications and CTO‐PCI with more favorable periprocedural composite safety outcomes, particularly in less complex lesions. Registration: URL: https://clinicaltrials.gov ; Unique identifier: NCT07373678.

Background: The anatomical location of left anterior descending artery (LAD) chronic total occlusion (CTO) may influence procedural complexity and technical success beyond conventional CTO scores. Aims: We evaluated the association between LAD CTO location and procedural characteristics and outcomes. Methods: Consecutive patients undergoing LAD CTO percutaneous coronary intervention at three centers between 2019 and 2026 were classified as having ostial, proximal, or mid/distal CTOs. Lesion complexity, crossing strategy, resource utilization, and in‐hospital outcomes were compared. Multivariable logistic regression was adjusted for clinical characteristics and either the J‐CTO or EuroCTO score. Results: Among 2157 CTO procedures, 644 involved the LAD: 81 ostial, 144 proximal, and 419 mid/distal lesions. Ostial CTOs had greater anatomical complexity and required a retrograde approach more frequently than proximal and mid/distal lesions (43.2% vs. 20.1% vs. 14.1%; p < 0.001). They were also associated with longer procedures, greater guidewire use, and higher contrast volume. Technical success was lower in ostial lesions (77.8% vs. 89.6% vs. 92.6%; p < 0.001), whereas in‐hospital major adverse cardiovascular events were similar. Ostial location remained independently associated with lower technical success after adjustment for the J‐CTO score (OR, 0.43; 95% CI, 0.21–0.87; p = 0.019) or EuroCTO score (OR, 0.41; 95% CI, 0.20–0.84; p = 0.015). Conclusions: Ostial LAD CTOs require retrograde strategies more often and have lower technical success despite adjustment for established CTO scores.

Background: Intravascular ultrasound (IVUS)‐guided antegrade dissection and re‐entry (ADR) is an emerging strategy for chronic total occlusion (CTO) percutaneous coronary intervention (PCI). However, its adoption has been limited by the perceived requirement for dedicated IVUS systems and specialized puncture guidewires. We describe a guidewire manipulation‐directed IVUS‐guided ADR technique using widely available equipment. Case Summary: A patient with a complex left anterior descending artery CTO underwent guidewire manipulation‐directed IVUS‐guided ADR using a conventional long‐tip Insight LifeTech IVUS catheter and a handmade 45°‐shaped 12‐g polymer‐jacketed guidewire. Following lesion preparation, true‐lumen re‐entry was achieved by manipulating the guidewire relative to a largely stationary IVUS catheter rather than repeatedly repositioning the IVUS transducer. The high‐tip‐load polymer‐jacketed guidewire enabled controlled puncture and subsequent intraluminal advancement under IVUS guidance. The procedure resulted in successful microcatheter advancement, complete CTO recanalization, and implantation of three drug‐eluting stents with an excellent final angiographic result. Conclusion: This report demonstrates the technical feasibility of guidewire manipulation‐directed IVUS‐guided ADR without dedicated devices. A conventional long‐tip IVUS catheter and a polymer‐jacketed high‐tip‐load guidewire may represent a practical alternative when dedicated equipment is unavailable, potentially expanding the applicability of IVUS‐guided ADR. Further experience is required to establish the reproducibility and safety of this approach.

Background: Guidewire selection influences chronic total occlusion (CTO) percutaneous coronary intervention (PCI) success. High‐tip‐load (>1.5 g) polymer‐jacketed guidewires (PJWs) combine penetration capability and lubricity, but comparative data versus non‐polymer‐jacketed penetration wires are limited. Aims: To compare procedural outcomes between high‐tip‐load PJWs and non‐PJW penetration guidewires in CTO PCI. Methods: We retrospectively analyzed 1,850 consecutive CTO PCI procedures performed between January 2020 and June 2025. The analytical cohort comprised 220 PJW and 642 non‐PJW procedures. Inverse probability of treatment weighting (IPTW) adjusted for 39 covariates; a propensity‐score‐matched sensitivity analysis yielded 208 pairs. Results: After IPTW adjustment, PJW use was associated with higher antegrade recanalization (OR 1.79, 95% CI 1.06–3.02; p = 0.028), whereas procedural success was not significantly different (OR 2.10, 95% CI 0.97–4.52; p = 0.059). Procedure time and air kerma were lower with PJWs. Unadjusted perforation rates did not differ (4.1% vs 5.1%; OR 0.79, 95% CI 0.37–1.67; p = 0.530), whereas the matched analysis suggested fewer perforations with PJWs (3.4% vs 8.2%; OR 0.39, 95% CI 0.16–0.97; p = 0.042). Because only 24 matched events occurred, this safety finding should be considered hypothesis‐generating. In‐hospital major adverse cardiac events did not differ ( p = 0.954). Conclusion: High‐tip‐load PJWs achieved comparable procedural success, higher antegrade recanalization, improved procedural efficiency, and a potential matched‐cohort safety signal. They may be considered before escalation to high‐force penetration wires.

Background: Evidence regarding an “only drug-coated balloon (DCB)” strategy in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) remains limited, particularly in complex all-comer populations. We aimed to evaluate the feasibility, safety, and mid-term outcomes of an only DCB strategy in consecutive patients undergoing contemporary CTO PCI. Methods: This multicenter observational study included consecutive CTO PCI procedures performed between January 2024 and April 2026 at three high-volume CTO centers. All procedures were initially attempted using an intention-to-treat “only DCB” strategy. The primary endpoint was major adverse cardiac and cerebrovascular events (MACCE), defined as cardiac death, target lesion revascularization (TLR), target vessel myocardial infarction, or stroke. Results: A total of 457 CTO PCI procedures were evaluated. After excluding unsuccessful guidewire crossing procedures, 423 lesions underwent lesion preparation using the only DCB protocol. Final treatment with an “only DCB” strategy was achieved in 248 lesions, corresponding to a feasibility rate of 58.62%. Mean J-CTO score was 1.97 ± 1.04. Antegrade wiring was used in 95.2% of procedures, whereas retrograde wiring was used in 16.9%. Mean follow-up duration was 231.1 ± 130.3 days. MACCE occurred in 28 patients (13.9%), and target vessel failure in 27 (13.4%). Follow-up mortality occurred in one patient (0.5%), and no patient had a stroke. Patients with angiographic restenosis ≥70% had smaller final minimum lumen diameter (1.69 ± 0.64 mm vs. 2.23 ± 0.80 mm; p = 0.001). Among patients with angiographic follow-up, late lumen gain was observed in 55.5% of lesions, whereas lumen gain>0.2 mm was observed in 45.4%, supporting positive vessel remodeling after DCB treatment. Conclusions: In an all-comer CTO PCI population, an only DCB strategy appears feasible in more than half of patients, with acceptable mid-term clinical and angiographic outcomes.

Background: Radial artery spasm (RAS) remains a clinically relevant limitation of the transradial approach (TRA). Aims: This study aimed to evaluate the influence of the distance between the radial artery puncture site and the radial styloid process on RAS and access‐site complications. Methods: This prospective, single‐center, randomized, single‐blind trial enrolled 380 patients undergoing diagnostic coronary angiography or percutaneous coronary intervention via TRA. Using fluoroscopic identification of the radial styloid process as a fixed anatomical reference, patients were randomized 1:1 to Near‐Styloid (0–20 mm) or Far‐Styloid (21–40 mm) puncture. The primary endpoint was clinical RAS. Secondary endpoints included puncture efficiency, pain scores, crossover, and access‐site complications, including radial artery occlusion (RAO) and hematoma. Results: Clinical RAS occurred in 14.7% of the Near‐Styloid group and 17.9% of the Far‐Styloid group ( p = 0.488). First‐attempt puncture success was significantly higher with Near‐Styloid access (74.2% vs. 58.4%, p = 0.002), with shorter puncture time (median 20 vs. 30 s, p < 0.001) and fewer puncture attempts ( p = 0.003). Procedural characteristics and fluoroscopy parameters were similar between groups. Persistent forearm pain (3.2% vs. 8.4%, p = 0.048), RAO (1.6% vs. 6.8%, p = 0.019), and access‐site hematoma (1.1% vs. 5.8%, p = 0.020) were less frequent in the Near‐Styloid group. Conclusions: No statistically significant difference in clinical RAS was detected between puncture sites located closer to or farther from the radial styloid process. Near‐Styloid access was associated with improved puncture efficiency and lower rates of RAO and access‐site hematoma. As these findings were derived from secondary endpoint analyses, they should be considered exploratory and warrant confirmation in future multicenter studies. Trial Registration: ClinicalTrials.gov identifier: NCT07060820.

Background: Long‐term outcome in patients with chronic total occlusions (CTO) depends on the target vessel and proximity of the lesion. Aims: To investigate of the target vessel was associated with procedural efficacy and safety in patients with proximal CTO lesions. Methods: Patients treated for a CTO lesion in the European CTO registry (ERCTO) between January 1, 2021, and December 31, 2023, were included in the study. Patients were categorized based on the treated vessel and the proximity of the lesion. The outcome was compared between proximal lesions in the three native vessels. The co‐primary endpoints were procedural success and 30‐day safety. Procedural success was defined as technical success without in‐hospital major adverse cardiac events. Results: A total of 14,744 patients were screened, and 7128 were included in the analysis of proximal CTO PCI. Technical success rates proximal in the three native vessel territories were 91.0% (left anterior descending [LAD]), 92.1% (left circumflex [LCX]), and 88.5% (right coronary artery [RCA]). In the adjusted analysis, the probability of procedural success was higher for LCX compared to RCA, but not for the LAD (OR (95% CI): LCX: 1.35, (1.05−1.75); LAD: 1.06 [0.86–1.31]). The adjusted 30‐day safety was better in the LAD, but not LCX, compared with RCA (LAD: OR 0.69, 95% CI: 0.50; 0.94, LCX: OR 0.77, 95% CI 0.54; 1.09). Conclusions: Modern CTO PCI for proximal lesions generally yields a very high success rate. The procedure tends to be more successful in the LAD and LCX territories compared to the RCA, with LAD lesion treatment being the safest option.

Objective: To examine the incidence, predictors, and strategy-specific patterns of major in-hospital complications during contemporary chronic total occlusion percutaneous coronary intervention (CTO PCI) in a multicenter Turkish registry. Methods: This retrospective analysis of a prospective multicenter registry included 2375 consecutive CTO PCI procedures performed from January 2020 to February 2026. The primary endpoint comprised death, myocardial infarction (MI), stroke, treatment-requiring coronary perforation, donor-vessel complication, emergency repeat percutaneous coronary intervention, or emergency coronary artery bypass grafting. Myocardial infarction and stroke were based on site-reported fields without central adjudication. Predictors were evaluated using logistic regression, with 500 bootstrap resamples for internal validation. Results: Major complications occurred in 87 procedures (3.7%) and in-hospital death in 14 (0.6%). Event rates ranged from 1.3% in Japanese-Chronic Total Occlusion (J-CTO) 0-1 lesions to 7.3% in J-CTO ≥4 lesions and were 2.3% vs. 7.1% in planned antegrade-only vs. planned retrograde or hybrid procedures. With actual retrograde involvement, the complication rate was 8.1% vs. 2.2% without retrograde use (P < .001). Treatment-requiring perforation occurred in 52 procedures and donor-vessel complications in 22. The primary multiple logistic regression model yielded odds ratio (OR) of 1.02 per year for age (P = .042, 95% CI: 1.00-1.05); OR of 1.23 per 10 mm for CTO length (P = .002, 95% CI: 1.08-1.40); and OR of 1.92 for moderate or severe calcification (P = .005, 95% CI: 1.22-3.03). Model discrimination was area under the curve (AUC) of 0.668 (P < .001, 95% CI: 0.614-0.722); bootstrap optimism-corrected AUC = 0.643. Conclusion: Major complications occurred in 3.7% of procedures, with rates varying across J-CTO strata and planned strategy groups. These findings may inform preprocedural counseling and procedural planning.

Background: There is limited information on the use of drug‐coated balloons (DCBs) in chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Aims: To assess the frequency and outcomes of DCB use in CTO PCI. Objective: This study evaluated the frequency and outcomes of DCB use in a large, multicenter CTO PCI registry. Methods: We analyzed 12,146 patients who underwent 12,157 successful CTO PCIs at 59 centers from 2018 to 2025. Results: DCBs were used in 454 patients (3.7%) with increasing frequency over time ( p = 0.020). A DCB‐only strategy was used in 48.4% of the patients and a hybrid strategy combining DCBs and drug‐eluting stents (DES) was used in 51.6% of patients. Patients treated with DCB (both strategies) had low prevalence of comorbidities. Compared with the DES cases, DCB only cases had favorable angiographic characteristics, lower mean J‐CTO (Japanese CTO) score (1.83 ± 1.03 vs. 2.27 ± 1.23; p < 0.001), and similar technical success (96.3% vs. 97.3%; p = 0.640), and in‐hospital major adverse cardiac events (MACE). The hybrid and DCB‐only strategies had comparable technical success and in‐hospital MACE. During a median follow‐up of 323 (170–429) days, DCB only cases had lower MACE than the other strategies (hazard ratio [HR] 0.41, 95% CI 0.17–0.96, p = 0.040). After multivariable adjustment, the association remained significant (HR 0.39, 95% CI 0.16–0.92, p = 0.032). Conclusions: DCBs are increasingly being used in CTO PCI. A DCB only strategy was used in less complex lesions and was associated with similar technical success and in‐hospital MACE compared with hybrid or DES strategies. A DCB only strategy was associated with lower long‐term MACE.

Background: The impact of target vessel diameter on outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study. Aim: To compare the impact of target vessel diameter on CTO PCI outcomes. Methods: We examined the association of vessel diameter with clinical, angiographic characteristics, and procedural outcomes of CTO‐PCI in a large multicenter registry. The CTO vessels were classified as small (≤ 2.75 mm), medium (2.76−3.00 mm), and large (> 3.00 mm) diameter. Results: Among 13,423 patients who underwent CTO‐PCI at 47 centers between 2012 and 2024, the target CTO vessel was small in 4858 (36%), medium in 5393 (40%), and large in 3172 (24%). Compared with patients who had medium and large CTO target vessels, those who had small vessels were older and had a higher prevalence of diabetes, hypertension, dyslipidemia, and peripheral arterial disease. Large target vessel diameter CTOs had more complex angiographic characteristics such as higher J‐CTO scores, longer lesion length, and more complex angiographic characteristics. Compared with CTO PCI of small and large vessel patients, medium vessel patients had higher technical ( p = 0.008) and procedural ( p = 0.010) success. The incidence of perforation was higher in large‐diameter vessels. In multivariable logistic regression using restricted cubic spline analysis, a vessel diameter of 2.75−3.00 mm was associated with higher technical (OR 2.05 95% CI 1.12−3.76; p < 0.001) and procedural (OR 2.48 95% CI 1.49−4.13; p < 0.001) success compared with a vessel diameter of less than 2.75 or greater than 3.00 mm. Conclusions: Large and small CTO target vessels were associated with lower technical and procedural success compared with medium‐sized vessels.