The success rate of percutaneous coronary intervention (PCI) for chronic total occlusions (CTO) remains lower than for non-occlusive lesions, especially in complex CTOs. Furthermore, complications increase in prolonged and unsuccessful procedures, leading many CTO patients to be less frequently offered percutaneous revascularization.
When the initial attempt fails, a balloon dilation aimed at modifying the CTO is often performed, a strategy that has retrospectively shown to improve success rates in subsequent procedures.
The aim of the INVEST-CTO study was to determine whether, in patients with highly complex anatomical CTOs, a planned two-stage strategy—initial modification followed by a second procedure for complete recanalization—results in higher procedural success and improved safety.
The primary endpoint (PEP) was procedural success, defined as technical success without major adverse cardiac events (MACE: death, myocardial infarction, or clinically driven revascularization of the treated vessel). The secondary endpoint (SEP) was a 30-day safety composite.
A total of 153 patients were analyzed, with a mean age of 66 years, predominantly male. The most common presentation was stable coronary artery disease. The mean J-CTO score was 4, indicating high complexity. The right coronary artery was most frequently involved (66%), followed by the left anterior descending (16%) and the circumflex (16%).
Regarding the PEP, the procedural success rate was 86.7% (95% CI 80.3–91.7; p < 0.05). For the SEP, the 30-day composite adverse event rate was 4.6%, suggesting a favorable safety profile.
Conclusion
A planned two-stage strategy for complex CTO intervention proved safe and effective. Initial modification of the CTO should be considered an early and rational approach in high-risk CTOs, with the potential to increase success rates and reduce complications.
Reference: Anja Øksnes, MD. TCT 2025.
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