Application of the J-CTO Score to Recanalization for In-Stent Chronic Total Occlusions

The application of the J-CTO score for in-stent chronic total occlusion (CTO) recanalization remains unclear. We aimed to compare the role of J-CTO score in in-stent and de novo CTO interventions using wiring-based intraplaque tracking techniques. The application of the J-CTO score to assess procedural feasibility and guidewire crossing time for in-stent (N = 74, 14.6%) and de novo CTO (N = 434, 85.4%) interventions were evaluated in consecutive 508 patients (64.1 ± 11.6 years, 446 men). Failed intraplaque tracking (N = 3) or guidewires crossing (N = 35) was considered procedural failures (38/508=7.5%). The procedural success rate for de novo CTOs significantly declined when the J-CTO score was ≥3 (85 vs ≤2: 97%, p < 0.001), but was comparable for in-stent CTOs (≥3: 96 vs ≤2: 100%, p = 0.400). Among 470 patients with successful recanalization, the guidewire crossing time ≥30 minutes was required less for in-stent than for de novo CTOs (OR=0.40, 95% CI=0.18-0.86) with J-CTO score ≥2 in multivariate analysis. For those with successful antegrade-only wiring, the guidewire crossing time shown by Kaplan-Meier curves was significantly related to the J-CTO score for either in-stent (N = 72) or de novo (N = 370) CTOs (both p < 0.001 by log-rank test). However, only blunt stump (15.0 ± 5.6 min) and occlusion ≥20mm (16.2 ± 5.6 min) were independent time-determining factors of guidewire crossing (both p < 0.01) for in-stent CTOs. In conclusion, with the intraplaque guidewire tracking techniques, the effects of the J-CTO score on procedural feasibility and guidewire crossing time differ for in-stent and de novo CTOs. Therefore, the J-CTO score should be cautiously interpreted during in-stent CTO interventions.