Temporal trends and outcomes of intravascular imaging in chronic total occlusion interventions: insights from the PROGRESS-CTO registry

Background In this study we investigated temporal trends, indications, practice variation, and outcomes associated with intravascular imaging (IVI) use in a large, multicenter chronic total occlusion (CTO) percutaneous coronary intervention (PCI) registry. Methods We analyzed CTO PCIs performed at 76 US and international centers in 2012-2026 in the PROGRESS-CTO registry. Patients were categorized according to IVI use. P value <0.05 was considered statistically significant. Results Among 18,024 CTO PCIs, IVI was used in 10,569 procedures (58.6%). IVI use increased over time. Intravascular ultrasound (IVUS) was the predominant modality, accounting for 98.1% of IVI-guided procedures. Following 1:1 propensity score matching, technical (85.8% vs 78.8%; p < 0.001) and procedural success (83.6% vs 78.1%, p = 0.003) remained higher in the IVUS-to-cross group. Difference was also pronounced when IVUS was used to cross ambiguous proximal cap: technical success was 85.1% versus 75.9% (OR, 1.81; 95% CI, 1.49-2.21), and procedural success was 83.0% versus 75.1% (OR, 1.63; 95% CI, 1.34-1.99). Centers contributing <100 cases had lower IVI use than centers contributing ≥100 cases (47.7% vs 58.7%; p < 0.001). Conclusion IVI use during CTO PCI continues to increase. Procedures in which IVUS was used to facilitate lesion crossing were associated with higher technical and procedural success rates and similar in-hospital MACE rates. The association with success was also pronounced when IVUS was used to resolve proximal cap ambiguity. IVI use varied significantly among participating centers, highlighting differences in practice patterns and adoption of IVI during CTO PCI.