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Observational Study
. 2025 May 12;18(9):1119-1130.
doi: 10.1016/j.jcin.2025.03.024.

Outcomes of Percutaneous Coronary Intervention for Chronic Total Occlusion With Bifurcation at Distal Cap

Mayu Sakuma  1 , Yuji Oikawa  2 , Koichi Kishi  3 , Yoshiaki Ito  4 , Hisayuki Okada  5 , Satoru Sumitsuji  6 , Ryohei Yoshikawa  7 , Tomohiro Kawasaki  8 , Hiroyuki Tanaka  9 , Osamu Katoh  10
Affiliations
Observational Study

Outcomes of Percutaneous Coronary Intervention for Chronic Total Occlusion With Bifurcation at Distal Cap

Mayu Sakuma et al. JACC Cardiovasc Interv. .

Abstract

Background: Bifurcation at the chronic total occlusion (CTO) distal cap is a key factor in the global CTO crossing algorithm.

Objectives: This study was performed to analyze procedural outcomes and adverse events and to evaluate strategies for managing bifurcation at the CTO distal cap.

Methods: We analyzed 11,627 patients enrolled in the Japanese CTO-PCI Expert Registry with an analyzable CTO distal cap between January 2014 and December 2022.

Results: A bifurcation lesion at the distal cap was present in 21.2% (n = 2,462 of 11,627) of all CTO lesions. The retrograde approach was used more frequently in cases with than without bifurcation (45.1% [n = 1,111 of 2,462] vs 40.5% [n = 3,716 of 9,165]; P < 0.001). Analyzing each of the 3 major coronary vessels, the distal cap bifurcation group more frequently required the retrograde approach in the right coronary artery (57.7% [n = 653 of 1,131] vs 49.4% [n = 2,297 of 4,648]; P < 0.001) and the left circumflex artery (28.4% [n = 141 of 497] vs 23.7% [n = 367 of 1,546]; P = 0.044). There were no significant differences in guidewire success, technical success, or procedural success rates between the two groups. However, the bifurcation group required a longer procedure time, used more contrast volume, and had a longer fluoroscopy time than the no bifurcation group.

Conclusions: Although there are concerns about the success rate when a bifurcation is present distal to the CTO, it has been shown that the combined use of the retrograde approach can achieve a high success rate equivalent to that of lesions without bifurcations.

Keywords: bifurcation at distal cap; chronic total occlusion; percutaneous coronary intervention.

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Conflict of interest statement

Funding Support and Author Disclosures This study was funded by the Japan Chronic Total Occlusion Intervention Specialist Council, Asahi Intecc, Abbott Vascular Japan, Biosensors Japan, Boston Scientific, Daiichi-Sankyo, Kaneka Medics, Medtronic Japan, NIPRO, and Terumo. Dr Oikawa has received speaker honoraria from Abbott Medical Japan, Boston Scientific, Medtronic Japan, NIPRO Corporation, Terumo Corporation, Kaneka Medix Corporation, and OrbusNeich Medical. Dr Ito has received speaker honoraria from Boston Scientific, Abbott Medical Japan, Terumo Corporation, and Medtronic Japan. Dr Yoshikawa has received speaker honoraria from Terumo Corporation, Abbott Medical Japan, Kaneka Medix Corporation, NIPRO Corporation, and OrbusNeich Medical. Dr Kawasaki has received speaker honoraria from Abbott Medical Japan, Boston Scientific, Japan Lifeline, Medtronic Japan, and Amgen. Dr Katoh has served as a consultant for Asahi Intecc, NIPRO Corporation, and Canon Medical System Corporation. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

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