Impact of Bifurcation Involvement and Location in Chronic Total Occlusion Percutaneous Coronary Intervention: Insights From the EuroCTO Registry.
Alice Moroni, Mohamed Ayoub, Sevket Gorgulu, Gerald S Werner, Nihat Kalay, Myron Zaczkiewicz, Jarosław Wójcik, Omer Goktekin, Hasim Tuner, Felix Woitek, Juergen Arenz, Gabriele Luigi Gasparini, Jakub Drozd, Nicolas Boudou, Bas E Schölzel, Roberto Diletti, Alexandre Avran, Carlo Di Mario, Kambis Mashayekhi, Pierfrancesco Agostoni
Author Information
Alice Moroni: HartCentrum, Ziekenhuis Netwerk Antwerpen (ZNA) Middelheim, Antwerp, Belgium.
Mohamed Ayoub: Division of Cardiology and Angiology, Heart Center University of Bochum, Bad Oeynhausen, Germany.
Sevket Gorgulu: Division of Cardiology, Biruni University Medical School, Istanbul, Turkey.
Gerald S Werner: Medizinische Klinik I, Klinikum Darmstadt GmbH, Darmstadt, Germany.
Nihat Kalay: Department of Cardiovascular Surgery, Faculty of Medicine, Erciyes University, Kayseri, Turkey.
Myron Zaczkiewicz: Internal Medicine and Cardiology, Heart Center Lahr/Baden, Lahr, Germany.
Jarosław Wójcik: Department of Cardiology, Hospital of Invasive Cardiology IKARDIA, Lublin, Poland.
Omer Goktekin: Department of Cardiology, Memorial Bahcelievler Hospital, Istanbul, Turkey.
Hasim Tuner: Department of Cardiology, Memorial Bahcelievler Hospital, Istanbul, Turkey.
Felix Woitek: Herzzentrum Dresden, Department of Internal Medicine and Cardiology, Technische Universität Dresden, Dresden, Germany.
Juergen Arenz: Division of Cardiology, Elisabeth Krankenhaus Recklinghausen, Recklinghausen, Germany.
Gabriele Luigi Gasparini: Cardio Center, IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy.
Jakub Drozd: Department of Cardiology, SP ZOZ MSWiA, Lublin, Poland.
Nicolas Boudou: Interventional Cardiology Unit, Clinique Saint-Augustin-Elsan, Bordeaux, France.
Bas E Schölzel: Department of Cardiology, Amphia Ziekenhuis, Breda, The Netherlands.
Roberto Diletti: Department of Cardiology, Erasmus MC Cardiovascular Institute, Thorax Center, Rotterdam, The Netherlands.
Alexandre Avran: Division of Cardiology, Valenciennes Hospital, Valenciennes, France.
Carlo Di Mario: Structural Interventional Cardiology, Department of Clinical & Experimental Medicine, Careggi University Hospital, Florence, Italy.
Kambis Mashayekhi: Internal Medicine and Cardiology, Heart Center Lahr/Baden, Lahr, Germany.
Bifurcation involvement close to or within the occluded segment poses increasing difficulties for chronic total occlusion (CTO)-percutaneous coronary intervention (PCI). However, this variable is not considered in the angiography-based CTO scoring systems nor has been extensively investigated in large multicenter series. Accordingly, we analyzed a CTO-PCI registry involving 92 European centers to explore the incidence, angiographic and procedural characteristics, and outcomes specific to CTO-PCIs with bifurcation involvement. A total of 3,948 procedures performed between January and November 2023 were examined (33% with bifurcation involvement). Among bifurcation lesions, 38% and 37% were located within 5 mm of the proximal and distal cap, respectively, 16% within the CTO body, and in 9% of cases proximal and distal bifurcations coexisted. When compared with lesions without bifurcation involvement, CTO bifurcation lesions had higher complexity (J-CTO 2.33 ± 1.21 vs 2.11 ± 1.27, p <0.001) and were associated with higher use of additional devices (dual-lumen microcatheter in 27.6% vs 8.4%, p <0.001, and intravascular ultrasound in 32.2% vs 21.7%, p <0.001). Radiation dose (1,544 [836 to 2,819] vs 1,298.5 [699.1 to 2,386.6] mGy, p <0.001) and contrast volume (230 [160 to 300] vs 190 [130 to 250] ml, p <0.001) were also higher. Technical success was similar (91.5% with bifurcation involvement vs 90.4% without bifurcation involvement, p = 0.271). However, the bifurcation lesions within the CTO segment (intralesion) were associated with lower technical success than the other bifurcation-location subgroups (83.7% vs 93.3% proximal, 93.4% distal, and 89.0% proximal and distal, p <0.001). On multivariable analysis, the presence of an intralesion bifurcation was independently associated with technical failure (odds ratio 2.04, 95% confidence interval 1.24 to 3.35, p = 0.005). In conclusion, bifurcations are present in approximately one-third of CTOs who underwent PCI. PCI of CTOs with bifurcation can be achieved with high success rates except for bifurcations within the occluded segment, which were associated with higher technical failure.
