Temporal trends in long coronary chronic total occlusion interventions: the Japanese CTO-PCI expert registry

Abstract Background Data on percutaneous coronary intervention (PCI) for long chronic total occlusions (CTOs) are limited. Purpose We sought to identify temporal trends in PCI for long CTOs. Methods We studied patients undergoing CTO-PCI between January 2015 and December 2022. Long CTO was defined as an occlusion length of ≥20 mm. Results The study population consisted of 10,302 patients, of whom 5,627 (54.6%) had a long CTO. Of these, 1,937 CTOs (34.4%) underwent primary retrograde approach and 1,486 CTOs (26.4%) underwent reverse controlled antegrade and retrograde tracking (CART). Reverse CART had a higher technical success rate than retrograde wiring and intravascular ultrasound (IVUS)-guided wiring after antegrade wiring (94.7%, 91.0%, and 81.6%, respectively), a longer guidewire crossing time (124, 92, and 85 minutes, respectively), and a higher incidence of coronary perforation (8.5%, 4.9%, and 6.3%, respectively) (P 0.01 for all). For long CTOs with good distal landing without side branches, the use of primary retrograde approach and reverse CART decreased over time from 39.9% to 27.3% and from 36.3% to 20.1%, respectively, whereas the use of antegrade wiring and IVUS-guided wiring after antegrade wiring increased from 46.6% to 58.7% and from 1.0% to 8.7%, respectively (P for trend 0.01 for all). For long CTOs with poor distal landing or a bifurcation at the distal cap, the use of primary retrograde approach and reverse CART did not decrease from 31.6% to 30.9% and from 24.8% to 23.1% (P for trend = 0.17 and 0.29, respectively). Conclusions In PCI for long CTOs, reverse CART was the most commonly used re-entry technique and had higher technical success, longer guidewire crossing time, and higher coronary perforation. For long CTOs with good distal landing without side branches, the use of primary retrograde approach and reverse CART decreased, whereas the use of antegrade wiring and IVUS-guided wiring after antegrade wiring increased.