Dr. Michael Megaly Leads A Decade-Long Analysis of CTO PCI Safety Published in JSCAI

A new propensity-matched analysis of more than 235,000 percutaneous coronary interventions finds no difference in 30-day mortality or ischemic stroke between chronic total occlusion PCI and non-CTO PCI across more than a decade of contemporary practice. Michael Megaly, MD, MS, FACC, FSCAI, interventional cardiologist at Integris Health Heart Hospital in Oklahoma City, is the senior and corresponding author of the study, published in the Journal of the Society for Cardiovascular Angiography & Interventions.

Chronic total occlusions remain the most technically demanding lesion subset in coronary intervention. Longer procedure times, greater lesion complexity, and higher rates of perforation and pericardial effusion have led to CTO PCI being characterized as a higher-risk procedure than conventional PCI. That characterization has shaped guideline language: current ACC/AHA/SCAI and ESC/EACTS documents recommend CTO PCI on a selective basis, citing procedural complexity and limited evidence of benefit in hard clinical endpoints. Whether that risk profile still holds after a decade of advances in technique, dedicated equipment, and operator training had not been well established.

Dr. Megaly and colleagues examined the TriNetX Research Network, a federated multicenter electronic health record database spanning more than 100 health care organizations. Adults undergoing PCI between January 2014 and November 2025 were identified and stratified into three predefined time frames: 2014-2017, 2018-2021, and 2022-November 2025, then propensity score-matched within each period. Patients presenting with acute myocardial infarction or cardiogenic shock were excluded to reduce confounding from acute instability. Of 235,340 patients undergoing PCI, 16,151 (6.86%) underwent CTO PCI.

After matching, 30-day all-cause mortality was 0.72% after CTO PCI versus 0.71% after non-CTO PCI, with no significant difference in any time frame. Ischemic stroke rates were likewise comparable at 1.64% versus 1.55%. CTO PCI was associated with a higher rate of pericardiocentesis (HR 2.16; 95% CI 1.14-4.07), though absolute rates were 0.20% versus 0.09%, an absolute risk difference of 0.11% and a number needed to harm of 909. Thirty-day CABG was consistently more frequent after CTO PCI across all three periods (2022-November 2025: HR 3.13; 95% CI 1.87-5.25), with absolute rates of 0.91% versus 0.28%. Among CTO PCI patients, the absolute incidence of CABG declined numerically from 1.07% in 2014-2015 to 0.45% in 2024-November 2025.

The authors interpret the CABG signal as reflecting referral for surgical revascularization in the setting of complex anatomy or incomplete percutaneous revascularization rather than acute procedural failure, a reading supported by the timing of events and the absence of any mortality difference. The findings position contemporary CTO PCI, performed with modern technique and dedicated equipment, as carrying a short-term safety profile comparable to conventional PCI.

The mortality finding is the central result. Across all three time frames and more than a decade of practice, patients undergoing PCI for chronic total occlusions died at the same rate within 30 days as matched patients undergoing conventional PCI: 0.72% versus 0.71%, with hazard ratios crossing unity in every era examined. This equivalence held despite the substantially greater technical demands of CTO PCI, and it held even as the procedure's higher rates of pericardiocentesis and downstream CABG were confirmed. Neither of those differences translated into excess death. In a lesion subset long characterized as high risk, the outcome that matters most to patients showed no penalty.

The study reflects an international collaboration including investigators from the Minneapolis Heart Institute, Henry Ford Hospital, Columbia University Irving Medical Center, Massachusetts General Hospital, and centers in Germany and Switzerland.

Ramadan, M.A., Karara, M.Y., Doma, M.M., Cogar, M.B., Mashayekhi, M.K., Alaswad, M.K., Leibundgut, M.G., Barboza, M.J.S., Khatri, M.J.J., Rinfret, M.S., Brilakis E.S, Megaly M.S, 2026. Temporal Trends in 30-Day Outcomes After CTO PCI Versus Non-CTO PCI: A Decade-Long Propensity-Matched Analysis. Journal of the Society for Cardiovascular Angiography & Interventions, p.105620.

Dr. Michael Megaly specializes in complex and high-risk coronary interventions, chronic total occlusion (CTO) PCI, surgical turn-downs, complex peripheral artery disease, and limb salvage at Integris Health Heart Hospital in Oklahoma City.