The Houston Methodist CTO-PCI Registry: Contemporary risk profile, procedural characteristics, and outcomes of patients undergoing percutaneous coronary intervention for chronic total occlusion

Background: Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) remains technically challenging, with ongoing debate about procedural success predictors and long-term outcomes. We report real-world data from the Houston Methodist CTO PCI Registry to characterize procedural success, safety, and mid- to long-term outcomes. Methods: We retrospectively analyzed 507 patients undergoing CTO PCI between 2018 and 2023. Baseline clinical characteristics, procedural details, and outcomes including procedural success, in-hospital complications, and follow-up events were evaluated. Multivariable logistic regression identified predictors of procedural success. Results: The cohort had a mean age of 65.3 ± 10.0 years, 20.9 % women, and a high prevalence of comorbidities (hypertension 96.1 %, diabetes 49.7 %). The mean J-CTO score was 1.8 ± 1.1. Procedural success was achieved in 81.2 % of cases, with low in-hospital mortality (0.4 %) and complication rates. Annual success rates improved from 72.7 % in 2018 to a peak of 86.7 % in 2020, reflecting growing operator experience and evolving techniques. Multivariable analysis showed that age (OR 0.97, 95 % CI [0.95–1.00]; p = 0.03), cumulative air kerma (OR 1.00, 95 % CI [1.00–1.00]; p = 0.003) and lesion length (OR 1.05, 95 % CI [1.03–1.07], p < 0.001) were independent predictors of success. KM analysis revealed a 2-year overall survival of 91.4 %, freedom from clinically driven target lesion revascularization (TLR) of 93.6 % at 2 years, and event-free survival from target lesion failure (TLF) of approximately 85 % at 2 years. At a median follow-up of 745 days, all-cause mortality was 9.2 %, and TLR occurred in 2.4 % of patients. Conclusion: CTO PCI can be performed safely with high success rates and favorable mid- to long-term outcomes in a complex population. Procedural success is primarily driven by lesion-specific factors rather than clinical comorbidities. These findings support the continued evolution and application of CTO PCI in appropriately selected patients.