Key result
CTO PCI is linked to ~69% higher 30-day bleeding risk vs. non-CTO PCI.
Why the study?
Comparative outcomes regarding bleeding events after CTO PCI versus non-CTO PCI remain limited despite known higher adverse event rates with CTO PCI.
Does CTO PCI increase bleeding events compared to non-CTO PCI in patients undergoing clinically indicated percutaneous coronary intervention?
Observational (n=8,264)
Yes
Does CTO PCI increase bleeding events compared to non-CTO PCI in patients undergoing clinically indicated percutaneous coronary intervention?
The apparent higher incidence of bleeding complications following CTO PCI compared to non-CTO PCI is largely driven by modifiable and non-modifiable patient and procedural characteristics—specifically femoral access and peripheral artery disease—rather than the CTO procedure itself.
CTO PCI not independently tied to access-site bleeding; leaves open whether radial access or risk-factor modification alters unadjusted rates.
Background Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is known for higher adverse event rates compared with non-CTO PCI. Comparative outcomes with respect to bleeding events remain limited. Objectives To evaluate bleeding events in patients undergoing CTO PCI compared with non-CTO PCI and to identify patient and procedural characteristics associated with bleeding events. Design and setting Prospective multicentre study of ongoing collected data registered within the South-East Netherlands Heart Registry (Zuid-Oost Nederland Hart Registratie, ZON-HR). Participants All consecutive patients with coronary artery disease undergoing clinically indicated PCI are included in the ZON-HR since November 2020. Results At the time of analyses, the ZON-HR consisted of 8264 included patients with 30-day follow-up between November 2020 and December 2023. A total of 8162 patients were included once in the registry. CTO PCI was performed in 410 (5.0%) patients and non-CTO PCI in 7854 (95.0%) patients. Bleeding events occurred more frequently in patients undergoing CTO PCI compared with non-CTO PCI (9.0% vs 5.4%, p<0.01), driven by a significantly higher rate of access-site bleeding events (7.6% vs 3.2%, p<0.01). After multivariable analysis, CTO was not significantly associated with the occurrence of access-site bleeding events (adjusted HR (aHR) 1.39 (95% CI 0.92 to 2.11)). Access-site bleeding events were associated with female sex (aHR 1.71 (95% CI 1.34 to 2.18)), peripheral artery disease (aHR 1.39 (95% CI 1.02 to 1.89)), oral anticoagulation use (aHR 1.34 (95% CI 1.00 to 1.78)), femoral artery access (aHR 2.90 (95% CI 2.08 to 4.05)) and left main PCI (aHR 1.50 (95% CI 1.04 to 2.14)). Conclusions The incidence of bleeding events is higher in patients undergoing CTO PCI and particularly driven by access-site bleeding events. The apparent correlation is attributed to non-modifiable and modifiable patient-related and procedure-related characteristics rather than the CTO PCI itself. Trial registration number NCT06512493 .
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Griffioen et al. (2026) conducted an observational in Coronary artery disease undergoing clinically indicated percutaneous coronary intervention (n=8,264). CTO PCI vs. Non-CTO PCI was evaluated on Bleeding events (BARC type 2, 3 or 5) at 30 days (HR 1.69, 95% CI 1.21 to 2.36, p=<0.01). CTO PCI was associated with a higher unadjusted rate of bleeding events compared with non-CTO PCI (9.0% vs 5.4%), but was not independently associated with access-site bleeding after adjustment.
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