Preservation of Distal Cap Bifurcation in Chronic Total Occlusion by Tip-Detection Antegrade Dissection Re-entry Method: A Retrospective Analysis

Background Preservation of distal side branches (SBs) during chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is crucial to maintain myocardial perfusion and optimize procedural outcomes. The tip-detection antegrade dissection re-entry (TDADR) technique is an advanced intravascular ultrasound-guided approach designed to improve re-entry precision, minimize vessel injury, and facilitate preservation of SBs at the distal cap of CTO lesions. This study explored factors associated with successful distal cap bifurcation preservation using TDADR in CTO PCI. Methods This single-center, retrospective study analyzed 30 patients who underwent CTO PCI using TDADR for lesions with a distal cap bifurcation. The primary outcome was distal cap bifurcation success, defined as achieving final Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow in both the main vessel and the SB. Lesion and procedural characteristics were compared between the distal cap bifurcation success and failure groups. Exploratory multivariate logistic regression was performed to identify factors associated with failure. Results Distal cap bifurcation success was achieved in 56.7% of patients (n = 17). In the exploratory multivariate analysis, pre-existing SB stenosis was highly associated with failure (odds ratio [OR], 20.13; 95% CI, 1.28-317.58; P = .033). Presence of a proximal bifurcation lesion was associated with a higher likelihood of success (OR, 0.32; 95% CI, 0.002-0.495; P = .014). Successful procedures were significantly more efficient, with shorter procedural times (184.7 vs 244.2 minutes, P = .01) and lower fluoroscopy times (81.1 vs 109.0 minutes, P = .02). Conclusions Successful distal cap bifurcation preservation was achieved in just over half of cases treated with the TDADR approach. While bifurcation anatomy was associated with success, SB stenosis emerged as the critical risk factor of failure. These hypothesis-generating findings underscore the importance of preprocedural lesion assessment to guide strategy and improve outcomes in complex CTO interventions, particularly TDADR.