Distal Vessel Diameter and Antegrade Crossing Success in Chronic Total Occlusion Percutaneous Coronary Intervention

Background Chronic total occlusion (CTO) is a particularly challenging subtype of ischemic heart disease, significantly elevating the risk of heart failure and sudden cardiac death. Percutaneous coronary intervention (PCI) is the primary revascularization approach. However, the success rate of antegrade PCI (A-PCI) for CTO remains relatively low. Although the distal vessel diameter is recognized as a critical anatomical parameter in A-PCI, it has received limited attention in studies of related populations. Methods This retrospective study included 502 CTO cases treated with antegrade PCI from July 2023 to September 2024. The relationship between distal vessel diameter and antegrade crossing success rate was investigated using logistic regression analysis and receiver operating characteristic curve analysis. Results Antegrade crossing success was achieved in 72.5% (364/502). The distal vessel diameter was significantly smaller in the failure group (1.60 ± 0.39 mm) compared to the success group (1.94 ± 0.41 mm; p < 0.001). In the multivariate logistic regression, distal vessel diameter was the most potent independent predictor of success. Each 0.5 mm increase in diameter was associated with more than triple the odds of successful crossing (OR: 3.06; 95% CI: 2.22-4.32; p < 0.001). This positive predictor had a greater predictive magnitude than the strongest negative predictor, proximal cap ambiguity (OR: 0.35; 95% CI: 0.21-0.58; p < 0.001). Conclusion Distal vessel diameter is the most powerful independent angiographic predictor of antegrade crossing success in CTO-PCI, with a predictive significance surpassing that of established proximal lesion characteristics like cap ambiguity.