Percutaneous Coronary Intervention of Chronic Total Occlusions Involving a Bifurcation: Insights From the PROGRESS-CTO Registry

Background The impact of bifurcations at the proximal or distal cap on the outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study. Methods We analyzed the clinical, angiographic, and procedural data of 6,066 cases performed in patients between 2012-2020 in a global CTO PCI registry. We compared 4 groups according to bifurcation location: “proximal and distal cap”, “proximal cap only”, “distal cap only” and “no bifurcation”. Results The CTO involved a bifurcation in 67% cases, as follows: proximal cap (n=2006, 33%), distal cap (n=815, 13%), or both caps (n=1268, 21%). “Proximal and distal cap” patients were more likely to have had prior myocardial infarction when compared with “proximal cap only”, “distal cap only” and “no bifurcation” (52% vs 45% vs 42% vs 44%, p<0.001). “Proximal and distal cap” cases had higher J-CTO (2.9 ± 1.1 vs 2.5 ± 1.2 vs 2.4 ± 1.3 vs 2 ± 1.3, p<0.0001) and greater use of the retrograde approach (47% vs 40% vs 30% vs 20%, p<0.0001). Technical success was significantly lower in the “proximal and distal cap” group (79% vs 85% vs 85% vs 90%, p<0.0001), with major adverse cardiovascular event rates being similar (2.3% vs 2.3% vs 1.6% vs 1.3%, p=0.06). Compared with no bifurcation, the presence of any bifurcation was associated with higher J-CTO score (2.6 ± 1.2 vs 2 ± 1.3, p<0.0001) and lower technical success (83% vs 90%, p<0.0001). Conclusion More than two thirds of CTO PCIs involve a bifurcation, which is associated with lower technical success but similar risk for complications.