Clinical Impact of Location on the Outcomes of Left Anterior Descending Artery Chronic Total Occlusion Percutaneous Coronary Intervention

BACKGROUND: The anatomical location of left anterior descending artery (LAD) chronic total occlusion (CTO) may influence procedural complexity and technical success beyond conventional CTO scores. AIMS: We evaluated the association between LAD CTO location and procedural characteristics and outcomes. METHODS: Consecutive patients undergoing LAD CTO percutaneous coronary intervention at three centers between 2019 and 2026 were classified as having ostial, proximal, or mid/distal CTOs. Lesion complexity, crossing strategy, resource utilization, and in-hospital outcomes were compared. Multivariable logistic regression was adjusted for clinical characteristics and either the J-CTO or EuroCTO score. RESULTS: Among 2157 CTO procedures, 644 involved the LAD: 81 ostial, 144 proximal, and 419 mid/distal lesions. Ostial CTOs had greater anatomical complexity and required a retrograde approach more frequently than proximal and mid/distal lesions (43.2% vs. 20.1% vs. 14.1%; p < 0.001). They were also associated with longer procedures, greater guidewire use, and higher contrast volume. Technical success was lower in ostial lesions (77.8% vs. 89.6% vs. 92.6%; p < 0.001), whereas in-hospital major adverse cardiovascular events were similar. Ostial location remained independently associated with lower technical success after adjustment for the J-CTO score (OR, 0.43; 95% CI, 0.21-0.87; p = 0.019) or EuroCTO score (OR, 0.41; 95% CI, 0.20-0.84; p = 0.015). CONCLUSIONS: Ostial LAD CTOs require retrograde strategies more often and have lower technical success despite adjustment for established CTO scores.