Optimizing chronic total occlusion percutaneous coronary intervention: a comparative study of imaging-guided vs. conventional strategies

Background Coronary imaging guidance significantly improves outcomes in complex percutaneous coronary intervention (PCI). However, its impact on clinical and procedural outcomes during chronic total occlusions (CTO) PCI is still debated. Purpose This study aimed to compare different coronary imaging guidance strategies during CTO PCI versus an angiography-guided approach and their impact on procedural and clinical outcomes. Methods A total of 171 patients undergoing elective CTO-PCI at a high-volume European center were retrospectively evaluated based on coronary imaging strategies: angiography-guided only (n=48), IVUS- or CT-guided (n=82), or both IVUS- and CT-guided (n=41). The primary endpoint was procedural index, derived using a standardized Z score approach incorporating procedural time, fluoroscopic time, and contrast volume. Secondary outcomes included the individual procedural index components, number of guidewires and balloons, stent length, number, and diameter. Additional assessments included in-hospital MACE, coronary perforations, post-PCI creatinine levels, and the use of intense debulking techniques (rotational atherectomy and intravascular lithotripsy) were also evaluated. Logistic regression analysis was performed to assess the association between of coronary imaging guidance and intense debulking usage, with results expressed using Odds Ratios (OR) with 95% CI. Results Among 171 patients, procedural success was achieved in 154 patients (90.1%). Procedural index was significantly higher in the coronary imaging groups compared to the angiography-only group (-1.46 [-2.6-0.1] vs -0.33 [-1.0-1.4] vs 0.36 [-1.1-1.5]; p<0.001). Patients undergoing coronary imaging guidance had longer procedural time (p<0.001), fluoroscopic time (p=0.002) and higher contrast volume (p=0.03). Additionally, these patients had higher stent number (p=0.03), length (p=0.01) and diameter (p=0.003). A higher number of guidewires (p=0.005) and balloons (p=0.01) were also used in the imaging-guided groups. There were no significant differences for in-hospital MACE (p=0.7), coronary perforations (p=0.07), or post-PCI creatinine level (p=0.42). Logistic regression analysis showed that coronary imaging guidance independently predicted the use of intense debulking techniques (OR 2.0; 95% CI 1.3-3.0). Conclusions Coronary imaging guidance enhances plaque assessment, resulting in the use of more guidewires and balloons, higher stent number, diameter, and length, while resulting in higher procedural, fluoroscopic time and contrast volume without increasing complications rates. Coronary imaging approaches independently predicted intense debulking usage, facilitating optimal lesion preparation and PCI outcomes. These findings support safety, feasibility and procedural optimization benefits of intracoronary imaging during CTO-PCI.