Current practice of european operators in the treatment of chronic total occlusions with multivessel disease: insights from multivessel TALENT

Abstract Background Chronic total occlusions (CTO) in the setting of three-vessel disease (3VD) present a complex challenge in interventional cardiology. Patients with concurrent CTO and 3VD disease often have a higher ischemic burden, face increased procedural risks, and may experience lower rates of complete revascularization. Advances in percutaneous coronary intervention (PCI) strategies, operator expertise, and specialized equipment have gradually improved success rates, yet CTO PCI remains technically demanding, often requiring individualized approaches. The integration of contemporary techniques and collaborative decision-making is essential for optimizing outcomes in this high-risk population. Purpose We aimed to evaluate the prevalence of chronic total occlusion (CTO) among patients with de novo three-vessel disease (3VD), to assess the frequency and success rates of CTO intervention attempts, and to characterize treatment practices among European operators. This analysis was conducted within the population of a randomized PCI trial (Multivessel TALENT). Methods The Multivessel TALENT trial is a randomized, 1:1, multicenter study conducted at 54 European sites, designed as an open-label comparison of clinical outcomes between Supraflex Cruz (SES) and SYNERGY (EES) in patients with de novo three-vessel disease (3VD) without left main disease. The best PCI practice encompasses Heart Team consensus decisions informed by SYNTAX score II, independent core lab assessment of functional lesions using quantitative flow ratio (QFR), stent optimization with intravascular imaging, prasugrel monotherapy after a one-month DAPT and CTO lesions treatment by a locally accredited expert at the respective center. Each CTO lesion was evaluated by a corelab using the EuroCTO (CASTLE) 1 and J-CTO scores 2, with assessment of PCI approach: crossing strategy (antegrade/retrograde), crossing and technical success rates according to CTO-ARC Consensus Recommendations 3. Results Among 9961 lesions assessed by corelab in the current trial, 423 met the ARC-2 criteria for CTO. Among them, CTO interventions were attempted in 204 lesions (J-CTO score: 1.1(1.1), CASTLE score: 1.2(1.1)) of which 95.1% used an antegrade approach, 4.9% retrograde and cross-over 3.9%. Notably, 90.7% of all CTO procedures were performed by the locally accredited expert, and a high crossing (92.6%) and technical (90.1%) success rates were reported. Conclusions In the current study, we demonstrated the high feasibility and safety of PCI for CTO lesions in patients with 3VD. High rates of procedural success were achieved, primarily due to the expertise of accredited expert operators and the use of contemporary techniques, such as antegrade approaches and Heart Team decision-making.Characteristics and procedural outcomesFor image description, please refer to the figure legend and surrounding text.