Ostial Lesions Are Associated with More Complexity and Lower Success Rate in Chronic Total Occlusion Percutaneous Interventions

Basem Salloum; Yeliz Koc; Steffen Schnupp; Hesham Mady; Christian Mahnkopf

doi:doi:10.11648/j.ijcts.20251105.11

Research Article |

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Ostial Lesions Are Associated with More Complexity and Lower Success Rate in Chronic Total Occlusion Percutaneous Interventions

Basem Salloum^*

, Yeliz Koc

, Steffen Schnupp, Hesham Mady, Christian Mahnkopf

Published in International Journal of Cardiovascular and Thoracic Surgery (Volume 11, Issue 5)

Received: 15 June 2025 Accepted: 7 July 2025 Published: 10 October 2025

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Abstract

Aims: We aimed to evaluate the influence of ostial lesions on the predicted probability of success in patients undergoing percutaneous coronary interventions (PCIs) for chronic total occlusions (CTOs). Methods: 245 consecutive patients who underwent CTO PCIs at Coburg Hospital, Coburg, Germany between 2017 and 2023 were included. Patients with and without ostial lesions were compared. Logistic regression models were used to estimate the potential of ostial lesion as additional predictor for success beside J-Score. Results: 245 patients were included. Of those, 48 Patients (19.6%) had ostial lesions. The ostial lesion group exhibited significantly higher pro-B-type natriuretic peptide levels (1644 pg./ml vs. 963 pg./ml, p=0.034) than the non-ostial lesion group. The final success rate was lower in the ostial lesion group than in the non-ostial lesion group (64.6% vs. 81.7%, p=0.018). The ostial lesion group had higher J-scores than the non-ostial lesion group, indicating more complex lesions (median: 2.5 vs. 2.0, p=0.005). Antegrade access was more applied in non-ostial lesion group (89.8% vs. 68.8% p=0.001), whereas retrograde access was more applied in ostial lesion group. (33.3% vs. 7.6%, p=<0.001) A logistic regression analysis showed a statistically significant association between higher J-scores and ostial lesions (OR, 2.4; p=0.003). Conclusion: The presence of ostial CTO is associated with higher lesion complexity and lower technical and procedural success rates. Presence of ostial CTO might be included as an additional factor in the currently used CTO scores to predict the difficulty and success rate of CTO procedure.

Published in	International Journal of Cardiovascular and Thoracic Surgery (Volume 11, Issue 5)
DOI	10.11648/j.ijcts.20251105.11
Page(s)	63-73
Creative Commons	This is an Open Access article, distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution and reproduction in any medium or format, provided the original work is properly cited.
Copyright	Copyright © The Author(s), 2025. Published by Science Publishing Group

Keywords

Chronic Total Occlusion, Percutaneous Coronary Intervention, Ostial Lesions, Risk Prediction

1. Introduction

Chronic total occlusions (CTOs) are completely occluded coronary arteries with Thrombolysis in Myocardial Infarction (TIMI) flow of null of at least 3 months

[1]

. CTO is frequently associated with more severe symptoms and an increased risk of adverse cardiovascular events compared with other forms of coronary artery disease (CAD). Approximately 20-30% of patients undergoing coronary angiography present with CTOs

[2, 3]

. In comparison with medical therapy alone, EUROCTO and the IMPACTOR-CTO trials have reported greater improvement in angina frequency after successful CTO-percutaneous coronary intervention (PCI)

[4, 5]

CTO treatment presents unique challenges owing to the complexity of the blockages, necessitating specialized techniques and equipment for effective intervention

[6]

. The current success rate of CTO PCI has reached 90% in experienced centers

[7]

however specific subsets are associated with additional challenges and potentially lower success rates. These include in-stent CTOs, bifurcations in the context of CTOs, occlusions in patients with post-coronary artery bypass grafting (CABG) surgery, and ostial CTOs

[8-10]

The definition of an ostial lesion in CTO lacks standardization; some authors have used a 5-mm cutoff, whereas aorto-ostial lesions are defined in the SYNTAX score as being within 3 mm of the coronary arteries’ origin from the aorta

[11]

. Fang et al. investigated the effects of ostial left anterior descending (LAD) CTO on the complexity of the CTO procedure and found that such lesions resulted in higher complexity, as indicated by J-CTO and SYNTAX scores. Ostial LAD CTO PCI exhibited a marginally lower final success rate compared with other CTO PCIs, with longer procedure duration and fluoroscopic time and larger contrast volume

[12]

. Galassi et al. had studied the influence of ostial CTO lesion and developed a prediction score for technical failure including age ≥75 years (1 point), ostial location (1 point), and collateral filling Rentrop grade <2 (2 points), then stratifying procedures into 4 difficulty groups: easy (0), intermediate (1), difficult (2), and very difficult (3 or 4), with decreasing technical success rates

[13]

. Until now the presence of ostial CTO lesion is not included in the scoring process among the standard used CTO scores. We aimed to evaluate the influence of ostial lesions on the predicted probability of success in patients undergoing PCI for CTO using logistic regression analysis and to determine whether ostial CTO could serve as an additional predictive marker alongside the J-score.

2. Methods

2.1. Patient Population

We analyzed the clinical, angiographic, and procedural characteristics of 245 consecutive patients who underwent CTO PCIs between January 2017 and October 2023 at Coburg Hospital in Coburg, Germany. All patients were symptomatic, either with angina pectoris or with exertional dyspnea (New York Hear Association NYHA Classification) and met the CTO definition angiographically and had myocardial viability of the CTO vessel territory based on the findings of cardiac magnetic resonance imaging (CMRI) or myocardial perfusion scintigraphy. (Figure 1, Consort Flow Chart).

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Figure 1. Consort Flow Chart.

The cohort was divided into two groups (ostial CTO and non-ostial CTO) according to SYNTAX score

[14]

. The baseline demographics, angiographic characteristics, and procedural outcomes were compared in both groups. All procedural coronary angiograms were reviewed to assess the anatomy and morphology of the CTO segment and grade of collaterals.

The 3-months follow up was available for (n= 223, 91%) and it included a clinical examination, coronary angiography, 24-hours Holter electrocardiogram (ECG) and an echocardiography. 12-Months follow up (n= 227, 93%) was conducted with clinical examination and echocardiography. The data of procedures were retrospectively entered into the database. This study was approved by the institutional review board, and the requirement for informed consent was waived for this study.

2.2. Definitions

Ostial CTO lesions in our study were anatomically defined as total occlusions of either aorto-ostial or branch ostial lesions persisting for more than 3 months. These CTO ostial lesions were angiographically characterized according to the SYNTAX score

[11]

, as being within 3 mm of the origin of the coronary arteries. To assess lesion complexity, we utilized the J-score, Rentrop classification, and Werner classification for anatomical collaterals. Technical success was determined by a residual stenosis of ≤30% through visual analysis, coupled with thrombolysis in myocardial infarction TIMI 3 flow grade at the end of the procedure

[15]

. Additionally, the distal wire’s position within the true lumen was confirmed by either coronary angiography or intravascular ultrasonography. Procedural success was defined as a combination of technical success with no in-hospital major adverse cardiac events (MACEs) or contrast-induced nephropathy (24-48h after intervention). MACEs included cardiac death, myocardial infarction (MI), tamponade requiring either pericardiocentesis or surgery, recurrent symptoms requiring urgent repeat target vessel revascularization (with either PCI or coronary artery bypass grafting). Contrast-induced nephropathy was defined as an increase of 25% or 0.5 mg/dl in serum creatinine level at 24 to 48 h after PCI in comparison with baseline values

[16, 17]

2.3. Statistical Analyses

Baseline patient characteristics, angiographic data, and procedural parameters were compared between patients who underwent ostial CTO PCI and those who underwent other CTO PCIs. Variables are presented as means (M) ± standard deviations (SD), for continuous variables and as absolute (n) and relative frequencies (%) for categorical variables. The chi-squared test and Student’s t-test were used for categorical and continuous variables, respectively. Stepwise, univariate logistic regression analysis was performed to identify potential significant predictors for success. Parameters demonstrating significant differences in the univariate analysis were included in the multivariate analysis. A p-value <0.05 was considered statistically significant for all tests. Subsequently, 95% confidence intervals (CIs) were used to determine the precision of the estimated probabilities. Model fit was evaluated using the Akaike information criterion, with significance established at p<0.05. Statistical analyses were performed using SPSS version 29.0.1 (SPSS, Chicago, IL, USA) and R (R Core Team (2018). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. URL https://www.R-project.org/).

3. Results

3.1. Baseline Clinical Characteristics

The mean age at intervention within the non-ostial and also within the ostial lesion groups were 67±11 years, respectively, with no significant difference between the two groups (p=0.6). The ostial lesion group had a higher proportion of males than the non-ostial lesion group (83.3% vs. 74.1%), although this difference was not statistically significant (p=0.18). The ostial lesion group exhibited significantly higher pro-B-type natriuretic peptide (NT-Pro-BNP) levels (3304±6972 pg./ml vs. 2736±2683 pg/ml, p=0.034) and lower high-density lipoprotein levels (44.1±13.9 mg/dl vs. 39.1±13.6 mg/dl, p=0.018) than the non-ostial lesion group. Other clinical and laboratory parameters, including prevalence of prior diseases and cardiovascular risk factors (arterial hypertension: 178 [90.4%] vs. 45 [93.8%], p=0.5461; hyperlipidemia: 168 [85.3%] vs. 45 [93.8%], p=0.118; and diabetes mellitus: 75 [38%] vs. 20 [41.7%]. p=0. 65) and admission symptoms (angina pectoris: 94 [47.7%] vs. 28 [58.3%], p=0.19), did not show significant differences between the groups. The ejection fractions at presentation in the non-ostial and ostial lesion groups were 51.2%±12.4% and 49.4±13.0%, respectively (p=0.404) (Table 1).

Table 1. Baseline characteristics of study population.

Characteristics	Non-ostial lesion		Ostial lesion		Total		p-value
Characteristics	M	SD	M	SD	M	SD	p-value
Age of the patient at the intervention (yr)	67.2	10.7	67.4	10.6	67.2	10.6	0.6
Body-Mass-Index (kg/m²)	30.6	6.3	31.6	5.3	30.8	6.1	0.12
Pro-B-Type Natriuretic Peptide (pg/ml)	2735	2682	3304	6971	3188	6336	0.034
Low-density lipoprotein prior to the intervention (mg/dl)	100.6	45.1	93.6	46.8	99.3	45.3	0.29
High-density lipoprotein prior to the intervention (mg/dl)	44.1	13.9	39.1	13.6	43.1	13.9	0.018
Glucose levels at the time of intervention (mg/dl)	131.4	46.9	136.4	47.5	132.4	47	0.17
HbA1c at the time of intervention (%)	6.4	1.4	6.5	1.5	6.4	1.5	0.24
Glomerular filtration rate at the time of intervention (ml/min)	70.9	23.3	68.9	23	70.5	23.2	0.44
Serum Creatinine at the time of intervention (mg/dl)	1.2	0.7	1.2	0.3	1.2	0.7	0.12
Left ventricular ejection fraction at the time of intervention (%)	51.2	12.4	49.4	13	50.8	12.5	0.4

Characteristics	Non-ostial lesion		Ostial lesion		Total		p-value
Characteristics	N	%	N	%	N	%	p-value
Male	146	74.1%	40	83.3%	186	75.9%	0.18
Hypertension	178	90.4%	45	93.8%	223	91%	0.46
Diabetes mellitus	75	38%	20	41.7%	95	38.8%	0.65
Insulin dependent diabetes mellitus	34	17.3%	9	18.7%	43	17.5%	0.81
Smoker	61	31%	12	25%	73	29.8%	0.42
Family history of CTO or CAD	41	20.8%	10	20.8%	51	20.8%	0.99
Hyperlipidemia	168	85.3%	45	93.7%	213	86.9%	0.12
Prior intervention with coronary artery bypass grafting	14	7.1%	5	10.4%	19	7.8%	0.44
Prior percutaneous coronary intervention	139	70.6%	36	75%	175	71.4%	0.54
Prior stroke	20	10.1%	2	4.2%	22	9%	0.19
Chronic kidney disease	62	31.5%	21	43.7%	83	33.9%	0.11
Atrial fibrillation	45	23%	12	25%	57	23.5%	0.78
Existing lung disease prior to the intervention (COPD, Asthma)	25	12.8%	9	18.7%	34	14%	0.29
Left ventricular ejection fraction below 35%	28	14.2%	9	18.7%	37	15.1%	0.43
VES_or_VT at presentation	23	12%	6	13%	29	12%	0.8
Symptoms of angina pectoris	94	47.7%	28	58.3%	122	49.8%	0.19
NYHA Classification - The Stages of Heart Failure
NYHA I	93	47.2%	19	40%	112	46%	0.63
NYHA II	67	34%	21	44%	88	36%	0.63
NYHA III	33	17%	7	15%	40	16%	0.63
NYHA IV	4	2%	1	2%	5	2%	0.63

P-values resulting from Chi-Square test or Fisher exact test for categorical variables and Mann-Whitney test for continuous variables.

3.2. Anatomical and Lesion Characteristics

Our registry indicated that patients with prior CABG (total number 19 patients) were less likely to present with ostial CTOs than with non-ostial CTOs (7.1% vs. 10.4%, p=0.442). Compared with patients with non-ostial lesions, those with ostial lesions had a higher prevalence of three-vessel disease (75.0% vs. 56.9%, p=0.086). Ostial lesion occurrence was more likely to be seen in the right coronary artery than in the LAD and left circumflex artery, with incidence rates of 47.3%, 16.7%, and 33.3%, respectively.

Bridging collaterals were statistically significantly more prevalent in the non-ostial lesion group than in the ostial lesion group (38.6% vs. 16.7%, p=0.004). J-scores ≥3 were more common in the ostial lesion group than in the non-ostial lesion group, although the difference was not statistically significant (27.1% vs. 17.3% for J-score 3; 12.5% vs. 6.1% for J-score 4; and 10.4% vs. 3.6% for J-score 5, p=0.054) (Table 2).

3.3. Procedural Characteristics and Outcomes

The ostial lesion group used more contrast agent (median (IQR) 245 ml) compared with the non-ostial lesion group (median (IQR) 220 ml), although the difference was not statistically significant (p=0.321). However, the radiation dose was significantly higher in the ostial lesion group than in the non-ostial lesion group (9823 cGy×cm² vs. 7796 cGy×cm², p=0.034). Technical details indicated significantly less frequent use of the antegrade approach (68.8% vs. 89.9%, p<0.001) and a higher incidence of retrograde access (33.3% vs. 7.6%, p<0.001) in the ostial lesion group than in the non-ostial lesion group. First attempt success rates were not significantly different between non-ostial and ostial CTOs (65.5% vs. 52.1%, p=0.085), and the second attempt success rates were also comparable (16.2% for non-ostial CTOs vs. 12.5% for ostial CTOs, p= 0.521)). However, the overall success rate, after either the first or second attempt, was significantly higher in non-ostial CTOs than in ostial CTOs (81.7% vs. 64.6%, p=0.010).

The incidence rates of in-hospital major adverse cardiovascular events (MACEs) were not significantly different between the two groups. Moreover, the incidence rates of complications, such as perforation, tamponade, side branch occlusion, stroke, acute kidney injury (AKI), and various vessel complications, did not differ between the two groups (Table 2).

Table 2. Complications of patients with ostial lesion vs. patients without ostial lesions.

	Non-ostial lesion		Ostial lesion		Total		p-value
	N	%	N	%	N	%	p-value
Antegrade approach	177	89.8%	33	68.7%	210	85.7%	<0.001
Retrograde approach	15	7.6%	16	33.3%	31	12.6%	<0.001
Success_1st- Attempt	129	65.5%	25	52.1%	154	62.9%	0.085
Success_2nd- Attempt	32	16.2%	6	12.5%	38	15.5%	0.52
Final Success	161	81.7%	31	64.6%	192	78.4%	0.01
Perforation	15	7.6%	5	10.4%	20	8.2%	0.53
Cardiac tamponade	2	1%	1	2%	3	1.2%	0.55
Myocardial infarction (MI)	1	0.5%	1	2%	2	0.8%	0.28
Side_branch_occlusion	14	7.1%	6	12.5%	20	8.2%	0.22
Stroke	1	0.5%	0	0.0%	1	0.4%	0.62
Cardiopulmonary resuscitation (CPR)	4	2%	2	4.2%	6	2.4%	0.39
Death	1	0.5%	1	2%	2	0.8%	0.28
Acute kidney injury	9	4.6%	2	4.2%	11	4.5%	0.9
Vessel complication
Non-Complication	192	97.5%	47	98%	239	97.5%	0.9
Pseudoenurysm	3	1.5%	1	2.1%	4	1.6%
Hemorrhagic shock	1	0.5%	0	0%	1	0.4%
Vessel occlusion	1	0.5%	0	0%	1	0.4%
Graft occlusion within 3 months after intervention	5	2.7%	2	4.3%	7	3%	0.56
In-Stent-Restenosis within 3 months after intervention	7	3.8%	4	8.7%	11	4.8%	0.16
Myocardial infarction within 3 months after intervention	3	1.6%	1	2.2%	4	1.7%	0.8
Angina pectoris after 3 Months	34	18.5%	10	21.7%	44	19.1%	0.61
VES_or_VT after 3 Months	8	4.3%	1	2.2%	9	3.9%	0.5

P-values resulting from Chi-Square test or Fisher exact test.

4. Predictor Evaluation

The odds ratio OR of ostial lesion on success of CTO PCI is 0.41 (95% CI [0.20; 0.82], p = 0.011), indicating a significant reduced success rate for patients with ostial lesions. Adjusting for relevant risk factors diabetes mellitus, hypertension, age at CTO, sex, and the presence of lung disease the OR of success of ostial lesion does not change the effect (OR 0.41, 95% CI [0.20; 0.83], p = 0.013). However, none of the adjusting factors was statistically significant.

Both models show a low model fit with Nagelkerke’s R² of 0.04 and 0.06.

In order to enhance the model fit and the prediction accuracy established CTO-scores were incorporated in the model. Due to the limited number of cases in our population across the J-score groups (1–5), the J-score was categorized into two groups (≥3, <3), as investigated by Christopoulos et al.

[18]

(Figure 2). In a logistic regression model with an interaction term between J-score and the presence of an ostial lesion, the analysis showed that the coefficient for the ostial lesion was nonsignificant upon the addition of the J-score to the model (OR 0.72, 95% CI [0.22; 2.42], p=0.600). The predicted probabilities of success for the various combinations of J-score categories and ostial status revealed that in the J-score <3 group, ostial lesions had a lower chance of success compared with non-ostial lesions, although this difference was not statistically significant. Figure 3 illustrates the predicted probability of success with 95% CIs for each J-score category and each level of the ostial lesion variable.

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Figure 2. Illustrates a logistic regression model with a interaction term between J-score and the presence of an ostial lesion.

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Figure 3. Illustrates the predicted probability of success with 95% CIs for each J-score category and each level of the ostial lesion variable.

Treating the J-score as ordinal variable allows for a more nuanced interpretation of changes in the predicted probability of success with increasing J-score values. Figure 3 illustrates that for both groups, the predicted probability of success decreases as the J-score increases. The shaded areas represent the 95% CIs for the predictions, providing a sense of the uncertainty surrounding the estimated probabilities However, the rate of decrease differed between patient with and without ostial lesion. The non-ostial lesion group began with a higher probability of success at lower J-scores and decreased at a steadier rate. In contrast, the ostial lesion group started with a slightly lower probability of success and appeared to decrease more rapidly with increasing J-scores. The interaction effect can be determined by examining how the association between J-score and the probability of success varies between the non-ostial and ostial lesion groups. If the lines were parallel, there would be no interaction effect, and the difference between the two groups would remain constant across all J-scores. However, the lines were not parallel, particularly in figure 3, indicating that the effect of the J-score on the probability of success differs for non-ostial versus ostial lesions.

Patients presenting with ostial CTO had a lower median left ventricular ejection fraction (LVEF) compared with those with non-ostial CTO (50% vs. 55%, p=0.4). Additionally, patients with ostial CTO exhibited more signs of congestive heart failure, as evidenced by significantly higher NT-pro-BNP levels (1644 pg./ml vs. 963 pg./ml; p=0.034), than those without ostial CTO. The LVEF in patients with ostial CTOs improved by 5% from the time of presentation to the 12-month follow-up (p=0.6). This improvement was not observed in patients with non-ostial CTOs (figure 4).

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Figure 4. Illustrates the difference in the improvement of LVEF between ostial lesions and non-ostial lesions after CTO-PCI.

Performing ROC Analyses cut-off values of 0.64 for the with J-score and ostial lesion, interaction term and covariates and 0.80 for ostial lesion and covariates and 0.79 for J-score and covariates (see figure 5). Using these cut-off values a sensitivity of 27.54% (ostial lesion), 41.56% (J-score) and 50.00% (ostial lesion + J-score) and specificity of 85.71%, 87.35% and 87.03% can be reached.

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Figure 5. ROC-Analyses incorporating ostial lesion additionally to the established J-Score.

As can be seen in figure 5, incorporating ostial lesion additionally to the established J-Score increases sensitivity and specificity of prediction success of CTO PCI. The area under the ROC curve is 0.72 (95% CI [0.64; 0.80]) for ostial lesion + J-score, 0.64 (95% CI [0.55; 0.72]) for ostial lesion and 0.71 (95% CI [0.63; 0.79]) J-score only.

Looking at the accuracy, ostial lesion reaches an accuracy of 52.67%, J-score 72.84% and ostial lesion and J-score 78.19%.

5. Discussion

Given the relatively low incidence of successful interventions of ostial CTO lesions, the availability of a prediction score would be of extreme importance. Predictors of procedural and technical success in CTO procedures are crucial for planning and executing interventions. Several studies have established several scores that predict the success rate of CTO percutaneous coronary interventions (PCIs). The first one is the Japan CTO (J-CTO) score that estimates the likelihood of successful guidewire crossing within the first 30 min based on five variables: blunt stump, calcification, lesion tortuosity, prior failed attempt, and occlusion length ≥20 mm

[19]

. Another widely used score is the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO) score, which uses four angiographic characteristics: moderate/severe proximal vessel tortuosity, proximal cap ambiguity, circumflex coronary artery CTO, and absence of interventional collaterals – to predict technical success

[20]

. The Euro-CTO CASTLE score uses six variables to assess the likelihood of success: prior coronary artery bypass graft surgery, age (≥70 years), stump anatomy (blunt or invisible), tortuosity degree (severe or unseen), length of occlusion (≥20 mm), and extent of calcification (>50% of the segment)

[21]

. In the present study, we evaluated ostial lesion as candidate predictor.

5.1. Ostial Chronic Total Occlusion (CTO) Characteristics

Ostial CTOs accounted for 19.59% of all CTO PCIs, with aorto-ostial and side-branch ostial occlusions each representing 9.79%. These results are comparable with those from multicentric registries from 14 centers across the USA, Europe, and Russia

[22]

Our study demonstrated that patients presenting with ostial CTO had a lower mean left ventricular ejection fraction (LVEF) compared with those with non-ostial CTO. Additionally, patients with ostial CTO exhibited more signs of congestive heart failure, as evidenced by significantly higher NT-pro-BNP levels, than those without ostial CTO. The LVEF in patients with ostial CTOs improved by 5% from the time of presentation to the 12-month follow-up. This improvement was not observed in patients with non-ostial CTOs. This finding can be justified as the lesions’ locations in the proximal third of the coronary artery are considered prognostically more important than lesions located more distally owing to the larger extent of myocardium at risk and have the greatest potential to reduce ischemic burden and improve symptoms and clinical outcomes after their revascularization

[23]

5.2. Technical Difficulty of Ostial CTO

Our retrospective study highlighted the procedural challenges associated with ostial CTO lesions, including longer procedure times, increased use of contrast agent, and significantly higher radiation doses. The necessity of employing the retrograde approach for ostial CTO lesions was statistically significant compared with that of non-ostial CTOs. This was corroborated by findings from Fang et al. in their study of ostial LAD CTO

[12]

and from Tajti et al.

[22]

. The greater need for retrograde crossing to achieve technical success in ostial CTOs may explain the lower success rate observed in our results (non-ostial CTO 81.7% vs. ostial CTO 64.6%, p=0.018). The retrograde approach has a significantly lower success rate compared with the anterograde approach. This was demonstrated in a meta-analysis of 12 observational studies involving 10,240 patients by Megaly et al.

[24]

The widely used scores (J-score, PROGRESS-CTO score, and Euro-CTO CASTLE score) to predict the technical success of CTO PCI do not consider the presence of an ostial lesion as a predictive factor for procedural difficulty. Karacsonyi et al. compared these three scores and found that the J-CTO score had the best overall performance in predicting the technical success of CTO PCI

[25]

. Our study aimed to investigate the association between the J-CTO score and the presence of ostial CTOs as a potential predictive factor for procedural difficulty.

A retrospective study by Allana et al. (2023), which reviewed 8788 CTO PCIs performed at 35 centers in the USA and abroad from 2012 to 2022, found that ostial CTOs were associated with greater lesion complexity and reduced technical and procedural success rates

[26]

Ostial CTO was associated with a higher risk of procedural failure in two previous studies that developed CTO scoring systems

[13, 27]

. The J-CTO score demonstrated good discriminatory and calibration capacity for guidewire crossing within 30 min but not for the final success rate. The J-CTO score aids in predicting the complexity of CTO recanalization, and its simplicity supports its widespread use as a clinical tool

[28]

However, our study reveals that the prevalence of ostial CTO lesions is higher in patients with a J-Score of ≥ 3 and is more frequently observed in cases of three-vessel disease, both of which contribute to increased challenges during PCI-CTO procedures.

5.3. Clinical Relevance

The findings from the study highlight the importance of carefully planning interventions for patients with ostial CTO lesions and a J-Score of ≥ 3. Specifically, it is crucial to inform patients about potential complications, the expected duration of the procedure, and the likelihood of success. Additionally, having sufficient experience with the retrograde approach is essential to optimize outcomes.

6. Conclusion

The presence of ostial CTO is associated with higher lesion complexity and lower technical and procedural success rates. Further studies, based on our retrospective and the previous studies, require the inclusion of the presence of ostial CTO as a factor in the currently used CTO scores to predict the difficulty of CTO procedure.

7. Limitation

While this study acknowledges its retrospective nature, several additional limitations should be considered. The low model fit, as indicated by Nagelkerke R² values ranging from 0.04 to 0.06, suggests that the models explain only a small proportion of the variability in the outcome, which may limit the robustness of the findings. Furthermore, external validation in prospective or multicenter datasets is necessary to confirm the generalizability and applicability of the results across different populations and clinical settings.

Abbreviations

AKI	Acute Kidney Injury
AP	Angina Pectoris
CABG	Coronary Artery Bypass Grafting
CAD	Coronary Artery Disease
CASTLE Score	Chronic Total Coronary Occlusion Intervention Procedural Success Score From
CI	Confidence Interval
CMRI	Cardiac Magnetic Resonance Imaging
COPD	Chronic Obstructive Pulmonary Disease
CPR	Cardiopulmonary Resuscitation
CTO	Chronic Total Occlusions
ECG	Electrocardiogram
J-Score	J-CTO Score (Multicenter CTO Registry of Japan)
HbA1c	Hemoglobin A1c
IQR	Interquartile Range
ISR	Instent-Restenosis
LAD	Left Ascending Artery
LVEF	Left Ventricular Ejection Fraction
MACE	Major Adverse Cardiac Events
MI	Myocardial Infarction
NT-Pro-BNP	N-terminal pro–B-type Natriuretic Peptide
NYHA	New York Heart Association
OCT	Optical Coherence Tomography
OR	Odds Ratio
PCI	Percutaneous Coronary Interventions
PROGRESS-CTO	Prospective Global Registry for the Study of Chronic Total Occlusion Intervention
ROC	Receiver Operating Characteristic
SYNTAX Score	Synergy Between PCI With Taxus and Cardiac Surgery
TIMI	Thrombolysis in Myocardial Infarction
VES	Ventricular Extrasystole
VT	Ventricular Tachycardia

Acknowledgments

Dr. Salloum took part in the data evaluation and in the planning, writing, revising, and reviewing the final draft of this manuscript. All co-authors contributed fully in terms of the design of the study, the evaluation of data, the actual manuscript preparation, and the revision and approval of the final submitted manuscript. As the corresponding author, Dr Salloum that all authors have seen and approved the final text. All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

Conflicts of Interest

The authors declare no conflicts of interest.

References

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APA Style

Salloum, B., Koc, Y., Schnupp, S., Mady, H., Mahnkopf, C. (2025). Ostial Lesions Are Associated with More Complexity and Lower Success Rate in Chronic Total Occlusion Percutaneous Interventions. International Journal of Cardiovascular and Thoracic Surgery, 11(5), 63-73. https://doi.org/10.11648/j.ijcts.20251105.11

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ACS Style

Salloum, B.; Koc, Y.; Schnupp, S.; Mady, H.; Mahnkopf, C. Ostial Lesions Are Associated with More Complexity and Lower Success Rate in Chronic Total Occlusion Percutaneous Interventions. Int. J. Cardiovasc. Thorac. Surg. 2025, 11(5), 63-73. doi: 10.11648/j.ijcts.20251105.11

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AMA Style

Salloum B, Koc Y, Schnupp S, Mady H, Mahnkopf C. Ostial Lesions Are Associated with More Complexity and Lower Success Rate in Chronic Total Occlusion Percutaneous Interventions. Int J Cardiovasc Thorac Surg. 2025;11(5):63-73. doi: 10.11648/j.ijcts.20251105.11

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@article{10.11648/j.ijcts.20251105.11,
  author = {Basem Salloum and Yeliz Koc and Steffen Schnupp and Hesham Mady and Christian Mahnkopf},
  title = {Ostial Lesions Are Associated with More Complexity and Lower Success Rate in Chronic Total Occlusion Percutaneous Interventions
},
  journal = {International Journal of Cardiovascular and Thoracic Surgery},
  volume = {11},
  number = {5},
  pages = {63-73},
  doi = {10.11648/j.ijcts.20251105.11},
  url = {https://doi.org/10.11648/j.ijcts.20251105.11},
  eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.ijcts.20251105.11},
  abstract = {Aims: We aimed to evaluate the influence of ostial lesions on the predicted probability of success in patients undergoing percutaneous coronary interventions (PCIs) for chronic total occlusions (CTOs). Methods: 245 consecutive patients who underwent CTO PCIs at Coburg Hospital, Coburg, Germany between 2017 and 2023 were included. Patients with and without ostial lesions were compared. Logistic regression models were used to estimate the potential of ostial lesion as additional predictor for success beside J-Score. Results: 245 patients were included. Of those, 48 Patients (19.6%) had ostial lesions. The ostial lesion group exhibited significantly higher pro-B-type natriuretic peptide levels (1644 pg./ml vs. 963 pg./ml, p=0.034) than the non-ostial lesion group. The final success rate was lower in the ostial lesion group than in the non-ostial lesion group (64.6% vs. 81.7%, p=0.018). The ostial lesion group had higher J-scores than the non-ostial lesion group, indicating more complex lesions (median: 2.5 vs. 2.0, p=0.005). Antegrade access was more applied in non-ostial lesion group (89.8% vs. 68.8% p=0.001), whereas retrograde access was more applied in ostial lesion group. (33.3% vs. 7.6%, p=Conclusion: The presence of ostial CTO is associated with higher lesion complexity and lower technical and procedural success rates. Presence of ostial CTO might be included as an additional factor in the currently used CTO scores to predict the difficulty and success rate of CTO procedure.
},
 year = {2025}
}

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TY - JOUR
T1 - Ostial Lesions Are Associated with More Complexity and Lower Success Rate in Chronic Total Occlusion Percutaneous Interventions

AU - Basem Salloum
AU - Yeliz Koc
AU - Steffen Schnupp
AU - Hesham Mady
AU - Christian Mahnkopf
Y1 - 2025/10/10
PY - 2025
N1 - https://doi.org/10.11648/j.ijcts.20251105.11
DO - 10.11648/j.ijcts.20251105.11
T2 - International Journal of Cardiovascular and Thoracic Surgery
JF - International Journal of Cardiovascular and Thoracic Surgery
JO - International Journal of Cardiovascular and Thoracic Surgery
SP - 63
EP - 73
PB - Science Publishing Group
SN - 2575-4882
UR - https://doi.org/10.11648/j.ijcts.20251105.11
AB - Aims: We aimed to evaluate the influence of ostial lesions on the predicted probability of success in patients undergoing percutaneous coronary interventions (PCIs) for chronic total occlusions (CTOs). Methods: 245 consecutive patients who underwent CTO PCIs at Coburg Hospital, Coburg, Germany between 2017 and 2023 were included. Patients with and without ostial lesions were compared. Logistic regression models were used to estimate the potential of ostial lesion as additional predictor for success beside J-Score. Results: 245 patients were included. Of those, 48 Patients (19.6%) had ostial lesions. The ostial lesion group exhibited significantly higher pro-B-type natriuretic peptide levels (1644 pg./ml vs. 963 pg./ml, p=0.034) than the non-ostial lesion group. The final success rate was lower in the ostial lesion group than in the non-ostial lesion group (64.6% vs. 81.7%, p=0.018). The ostial lesion group had higher J-scores than the non-ostial lesion group, indicating more complex lesions (median: 2.5 vs. 2.0, p=0.005). Antegrade access was more applied in non-ostial lesion group (89.8% vs. 68.8% p=0.001), whereas retrograde access was more applied in ostial lesion group. (33.3% vs. 7.6%, p=Conclusion: The presence of ostial CTO is associated with higher lesion complexity and lower technical and procedural success rates. Presence of ostial CTO might be included as an additional factor in the currently used CTO scores to predict the difficulty and success rate of CTO procedure.

VL - 11
IS - 5
ER -

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Author Information

Basem Salloum

Department of Cardiology, Klinikum Coburg, Coburg, Germany

Contact Email

http://orcid.org/0000-0001-8429-8673
Yeliz Koc

Department of Gastroenterology, Klinikum Lichtenfels, Lichtenfels, Germany

http://orcid.org/0009-0000-5132-4951
Steffen Schnupp

Department of Cardiology, Klinikum Coburg, Coburg, Germany

Contact Email
Hesham Mady

Department of Cardiology, Klinikum Coburg, Coburg, Germany

Contact Email
Christian Mahnkopf

Department of Cardiology, Klinikum Coburg, Coburg, Germany

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APA Style

Salloum, B., Koc, Y., Schnupp, S., Mady, H., Mahnkopf, C. (2025). Ostial Lesions Are Associated with More Complexity and Lower Success Rate in Chronic Total Occlusion Percutaneous Interventions. International Journal of Cardiovascular and Thoracic Surgery, 11(5), 63-73. https://doi.org/10.11648/j.ijcts.20251105.11

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ACS Style

Salloum, B.; Koc, Y.; Schnupp, S.; Mady, H.; Mahnkopf, C. Ostial Lesions Are Associated with More Complexity and Lower Success Rate in Chronic Total Occlusion Percutaneous Interventions. Int. J. Cardiovasc. Thorac. Surg. 2025, 11(5), 63-73. doi: 10.11648/j.ijcts.20251105.11

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AMA Style

Salloum B, Koc Y, Schnupp S, Mady H, Mahnkopf C. Ostial Lesions Are Associated with More Complexity and Lower Success Rate in Chronic Total Occlusion Percutaneous Interventions. Int J Cardiovasc Thorac Surg. 2025;11(5):63-73. doi: 10.11648/j.ijcts.20251105.11

Copy | Download

@article{10.11648/j.ijcts.20251105.11,
  author = {Basem Salloum and Yeliz Koc and Steffen Schnupp and Hesham Mady and Christian Mahnkopf},
  title = {Ostial Lesions Are Associated with More Complexity and Lower Success Rate in Chronic Total Occlusion Percutaneous Interventions
},
  journal = {International Journal of Cardiovascular and Thoracic Surgery},
  volume = {11},
  number = {5},
  pages = {63-73},
  doi = {10.11648/j.ijcts.20251105.11},
  url = {https://doi.org/10.11648/j.ijcts.20251105.11},
  eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.ijcts.20251105.11},
  abstract = {Aims: We aimed to evaluate the influence of ostial lesions on the predicted probability of success in patients undergoing percutaneous coronary interventions (PCIs) for chronic total occlusions (CTOs). Methods: 245 consecutive patients who underwent CTO PCIs at Coburg Hospital, Coburg, Germany between 2017 and 2023 were included. Patients with and without ostial lesions were compared. Logistic regression models were used to estimate the potential of ostial lesion as additional predictor for success beside J-Score. Results: 245 patients were included. Of those, 48 Patients (19.6%) had ostial lesions. The ostial lesion group exhibited significantly higher pro-B-type natriuretic peptide levels (1644 pg./ml vs. 963 pg./ml, p=0.034) than the non-ostial lesion group. The final success rate was lower in the ostial lesion group than in the non-ostial lesion group (64.6% vs. 81.7%, p=0.018). The ostial lesion group had higher J-scores than the non-ostial lesion group, indicating more complex lesions (median: 2.5 vs. 2.0, p=0.005). Antegrade access was more applied in non-ostial lesion group (89.8% vs. 68.8% p=0.001), whereas retrograde access was more applied in ostial lesion group. (33.3% vs. 7.6%, p=Conclusion: The presence of ostial CTO is associated with higher lesion complexity and lower technical and procedural success rates. Presence of ostial CTO might be included as an additional factor in the currently used CTO scores to predict the difficulty and success rate of CTO procedure.
},
 year = {2025}
}

Copy | Download

TY - JOUR
T1 - Ostial Lesions Are Associated with More Complexity and Lower Success Rate in Chronic Total Occlusion Percutaneous Interventions

VL - 11
IS - 5
ER -

Copy | Download