Comparative Impact of Coronary Imaging Strategies in CTO-PCI: A Retrospective Single-Center Analysis

Background: Coronary imaging is increasingly used in chronic total occlusion percutaneous coronary intervention (CTO-PCI), but the impact of different imaging strategies on procedural decisions and outcomes remains unclear. Methods: We retrospectively analyzed 171 consecutive patients undergoing CTO-PCI, stratified by imaging strategy into four groups: angiography-only (n = 48), IVUS-guided (n = 42), CT-guided (n = 40) and CT + IVUS-guided (n = 41). Procedural and in-hospital clinical outcomes were compared. A multivariable logistic regression identified predictors of intense debulking techniques (defined as the use of rotational atherectomy or intravascular lithotripsy). Results: Imaging guidance was associated with progressively longer procedural (p < 0.001) and fluoroscopic time (p = 0.007). Similarly, an increased number of guidewires (p = 0.005) and balloons (p = 0.003) was used in the imaging groups, with the CT + IVUS groups showing the highest features. Regarding stenting characteristics, higher stent length and diameter (p = 0.01) were observed in the imaging groups. In patients with J-CTO score > 2, procedural success rates significantly increased with the use of coronary imaging (p = 0.01). Multivariable analysis showed that both J-CTO score (OR 2.0; 95% CI 1.3-3.0; p = 0.001) and imaging strategies (OR 1.6; 95% CI 1.02-2.4; p = 0.04) independently predicted the use of intense debulking techniques. Importantly, no significant differences were observed in in-hospital complications across groups. Conclusions: The use of coronary imaging, particularly the combination of IVUS and CT, is associated with more complex CTO lesions and led to increased procedural time, fluoroscopic time and more extensive stenting, as well as higher debulking usage. In complex CTO cases, coronary imaging was associated with higher procedural success rates. Imaging strategies independently predicted the need for advanced lesion preparation, beyond anatomical complexity, without compromising safety. Despite higher procedural demands, coronary imaging enables a more tailored and successful approach to CTO-PCI, particularly in complex cases. These findings underscore the pivotal role of multimodal imaging in the procedural planning and optimization of CTO-PCI.