Strategy Selection and Outcomes of Tip-Detection in CTO-PCI: Intraplaque Tracking vs Antegrade Dissection and Re-Entry.

BACKGROUND: The tip-detection (TD) method expands antegrade options for chronic total occlusion (CTO) percutaneous coronary intervention, but criteria for selecting TD intraplaque tracking (TD-IPT) vs TD antegrade dissection and re-entry (TD-ADR) remain unclear. OBJECTIVES: The authors evaluated factors associated with the initially selected TD strategy and procedural outcomes. METHODS: We retrospectively analyzed 73 TD-attempted CTO-percutaneous coronary intervention cases from November 2020 to December 2023 and classified them as TD-primary IPT (n = 37) or TD-primary ADR (n = 36). Procedural outcomes were evaluated in all cases, and secondary metrics in 69 successful cases. RESULTS: TD success was 97.3% (36/37; 95% CI: 85.8%-99.9%) and 97.2% (35/36; 95% CI: 85.5%-99.9%), and final procedural success was 94.6% (35/37; 95% CI: 81.8%-99.3%) and 97.2% (35/36; 95% CI: 85.5%-99.9%) in the TD-primary IPT and TD-primary ADR groups, respectively. TD-primary ADR was selected more often for J-CTO score ≥2 (83.3% [30/36] vs 62.2% [23/37]; P = 0.043) and severe calcification (47.2% [17/36] vs 2.7% [1/37]; P < 0.001). Among successful cases, lesion crossing time was shorter with TD-primary IPT (75 [51-108] vs 93 [63-137] minutes; P = 0.046), whereas stent length was shorter with TD-primary ADR (38 [28-54] vs 46 [38-64] mm; P = 0.041). In multivariable models, severe calcification was associated with longer lesion crossing time, and bending ≥45° was associated with longer stent length. CONCLUSIONS: TD-primary ADR was preferentially selected for complex, calcified CTOs. Procedural efficiency appeared driven mainly by lesion characteristics rather than the initial TD strategy, supporting individualized TD strategy selection based on lesion morphology and technical feasibility.