Prior CABG and native-vessel CTO PCI: lesion complexity, strategy planning, procedural burden, and technical success...

Prior coronary artery bypass grafting (CABG) has been associated with greater lesion complexity and lower success rates in chronic total occlusion (CTO) percutaneous coronary intervention (PCI). In native-vessel CTO PCI, prior CABG may also indicate greater preprocedural complexity and more advanced strategy planning. We examined whether prior CABG was associated with lesion complexity, strategy selection, procedural burden, and technical success in a contemporary multicenter registry.

We performed a retrospective analysis of a prospective multicenter CTO PCI registry including 1,800 consecutive native-vessel procedures performed between January 2020 and June 2025. Of these, 205 were performed in patients with prior CABG and 1,595 in patients without prior CABG. The primary endpoint was technical success, defined as final TIMI 3 flow with residual stenosis < 30%. The key secondary endpoint was procedural success, defined as technical success without in-hospital major adverse cardiac and cerebrovascular events.

Prior-CABG procedures had greater lesion complexity, more frequent planned retrograde/hybrid crossing, longer procedural and fluoroscopy times, higher dose-area product, and greater adjusted contrast use. Technical success was lower in prior-CABG procedures (85.9% vs. 93.3%, p < 0.001), as was procedural success (84.9% vs. 92.4%, p < 0.001). In multivariable analysis, prior CABG was independently associated with technical failure (adjusted OR, 1.94; 95% CI, 1.19-3.18; p = 0.008). Planned retrograde/hybrid strategy was also associated with technical failure (adjusted OR 2.82, 95% CI 1.81-4.40, p < 0.001), a finding interpreted as reflecting case selection and lesion difficulty rather than a causal effect of the strategy. In a companion model, prior CABG was independently associated with the selection of a planned retrograde/hybrid strategy (adjusted OR 2.03, 95% CI 1.40-2.96, p < 0.001).

In native-vessel CTO PCI, prior CABG was associated with more complex lesions, more frequent retrograde/hybrid planning, greater procedural burden, and lower technical success. However, its incremental prognostic value beyond the J-CTO score was limited. Prior CABG should therefore be interpreted primarily as a marker of an unfavorable procedural phenotype rather than as a standalone risk-stratification tool.