HydroDynamic Recanalization for Chronic Total Occlusion Percutaneous Coronary Intervention: Insights From the PROGRESS‐CTO Registry

BACKGROUND: HydroDynamic Recanalization (HDR) is a novel technique for crossing coronary chronic total occlusions (CTOs) that involves intraplaque contrast injection followed by polymer-jacketed guidewire advancement. AIM: The aim of this study is to compare the technical and procedural outcomes, and safety of CTO PCIs performed with HDR versus (vs.) without HDR. METHODS: We analyzed the baseline clinical and angiographic characteristics and outcomes of HDR-treated patients in the multicenter PROGRESS-CTO registry. RESULTS: Of 1807 CTO percutaneous coronary interventions (PCIs) (1797 patients) performed in 2025, HDR was utilized in 90 (5%) cases. HDR patients had similar baseline clinical characteristics with non-HDR patients, although a history of prior PCI was more common among HDR patients (75.3% vs. 60.2%, p = 0.006). HDR-treated patients were less likely to have interventional collaterals (38.2% vs. 55.4%, p = 0.002) but more likely to have in-stent restenosis (35.6% vs. 14.9%, p < 0.001). HDR cases had higher prevalence of blunt/no stump (62.2% vs. 50.1%, p = 0.025), smaller lesion diameter (2.88 ± 0.67 vs. 3.03 ± 0.55, p = 0.011), and less frequently side branch at the proximal cap (43.7% vs. 64.0%, p < 0.001). They had higher J-CTO (2.63 ± 1.10 vs. 2.29 ± 1.14, p = 0.006), PROGRESS-CTO (1.33 ± 1.02 vs. 1.13 ± 0.93, p = 0.048) and PROGRESS-CTO MACE (3.06 ± 1.55 vs. 2.65 ± 1.67, p = 0.014) scores. Antegrade wiring was both the first and the most successful crossing strategy in both groups. HDR cases had significantly longer procedural (131 [107, 174] vs. 109 [74, 151] min, p < 0.001), fluoroscopy (48 [34, 70] vs. 39 [25, 61]) min, p = 0.001), and crossing (39 [22, 86] vs. 25 [11, 56] min, p < 0.001) time compared with non-HDR cases. Technical success was lower in HDR patients (80.0% vs. 88.5%, p = 0.024), while MACE (1.1% vs. 2.6%, p = 0.7) was not different between the two groups. CONCLUSIONS: HDR was performed in 5% of CTO PCIs in 2025, in more complex lesions and was associated with lower technical success but similar MACE compared with patients who underwent CTO PCI without HDR.