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June 12, 2026Journal of the Society for Cardiovascular Angiography & InterventionsOpen Access

The Morphological and Mechanistic Impact of an Investment Procedure on Coronary Chronic Total Occlusions

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Key result

Upfront investment procedures cut median J-CTO scores by ~50%, driven by reduced proximal cap ambiguity.

  • P<.001
  • n=80

Why the study?

Although modification procedures improve subsequent CTO PCI success after failure, the anatomical impact and mechanism of benefit have never been systematically studied.

Does a planned investment procedure reduce occlusion complexity and improve morphology in high-risk coronary chronic total occlusions?

Population

First 80 consecutive patients returning for completion of CTO PCI

Comparison

Baseline angiographic characteristics prior to investment vs start of completion procedures

Design

Substudy of the Invest-CTO study

Authors

AØAnja ØksnesHaukeland University HospitalAMAkiko MaeharaCardiovascular Research FoundationBEBritt EnganHaukeland University Hospital

Discussion

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Overview

May simplify high-risk CTO anatomy for staged PCI; leaves open need for randomized trials on success.

Key Points

  • This study aims to examine the anatomical and mechanistic effects of an upfront investment procedure on chronic total occlusions during PCI.
  • 80 consecutive patients were included for completion of CTO PCI after an investment procedure.
  • Angiographic characteristics were compared at baseline and during completion procedures.
  • Intravascular ultrasound was used to analyze morphological changes post-wire crossing.
  • The median J-CTO score reduced from 4 to 2 (P < .001).
  • The vessel was successfully open in 28.8% of cases (n = 23).
  • Median lesion length decreased significantly from 28.2 mm to 15 mm (P < .001).

Study Design

Type

Cohort (n=80)

Structured PICO

Does a planned investment procedure reduce occlusion complexity and improve morphology in high-risk coronary chronic total occlusions?

P
Population
80 consecutive patients with chronic total occlusion returning for completion of a planned 2-stage percutaneous coronary intervention.
E
Exposure
Planned 2-stage CTO PCI with upfront "investment" procedure
C
Comparator
Baseline angiographic characteristics prior to the investment procedure
O
Outcome
Changes in angiographic characteristics (J-CTO score, proximal cap ambiguity, vessel course ambiguity, lesion length) and intravascular ultrasound morphologysurrogate

Main Result

Absolute Event Rate: 2% vs 4%

p-value: p=<.001

A planned investment procedure in high-risk CTO PCI significantly reduces angiographic occlusion complexity and facilitates subsequent wire crossing.

Cite This Study

Øksnes et al. (2026) conducted a cohort in chronic total occlusion (CTO) (n=80). upfront investment procedure vs. baseline prior to investment was evaluated on J-CTO score (p=<.001). An upfront investment procedure significantly reduced the median J-CTO score from 4 to 2 (P<0.001) and decreased proximal cap ambiguity from 77.5% to 12.5% in high-risk CTOs.

synapsesocial.com/papers/6a2bd11d6550ea4541ffe8bdhttps://doi.org/10.1016/j.jscai.2026.105447
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Also Consider

Synapse has enriched 5 closely related papers on similar clinical questions. Consider them for comparative context:

  1. 1Hybrid approach improves success of chronic total occlusion angioplasty2016 · 180 citations
  2. 2Percutaneous Recanalization of Chronically Occluded Coronary Arteries2005 · 527 citations
  3. 3Temporal Trends in Chronic Total Occlusion Interventions in Europe2018 · 157 citations
  4. 4Definitions and Clinical Trial Design Principles for Coronary Artery Chronic Total Occlusion Therapies: CTO-ARC Consensus Recommendations2021 · 311 citations
  5. 5Chronic Total Occlusions in Sweden – A Report from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR)2014 · 149 citations