A chronic total occlusion (CTO) is a completely blocked coronary artery that has been occluded for at least three months, affecting roughly one in five people undergoing coronary angiography. During a CTO PCI procedure, an interventional cardiologist accesses the artery through a small puncture in the wrist or groin, using specialized guidewires to navigate through or around the hardened blockage—sometimes via natural collateral channels from the opposite side. Once the path is established, balloons widen the vessel and drug-eluting stents are placed to maintain patency. Unlike acute heart attacks, CTOs develop slowly, allowing the body to develop compensatory collateral vessels that partially reroute blood flow, meaning many patients remain unaware of the blockage. However, collaterals often prove insufficient during exertion, causing chest tightness or breathlessness. The key clinical question is whether reopening the artery will meaningfully improve patient symptoms and function, rather than simply whether reopening is technically feasible. Understanding CTO PCI outcomes requires examining trial evidence and acknowledging genuine uncertainties in predicting individual patient benefit.

Coronary computed tomography angiography (CCTA)-guided percutaneous coronary intervention (PCI) demonstrates comparable efficacy to the established intravascular ultrasound (IVUS)-guided approach while offering superior pre-procedural planning benefits. An international randomized controlled trial presented at the Transcatheter Cardiovascular Therapeutics symposium and published in the New England Journal of Medicine evaluated 556 CCTA-guided PCI patients against 549 IVUS-guided PCI patients, all with fractional flow reserve values below 80 percent and significant coronary stenosis. Results showed CCTA-guided PCI was noninferior to IVUS guidance for target-vessel failure at one year (4.1 percent versus 4.6 percent), while achieving notably shorter procedure duration of 46 minutes compared to 63 minutes with IVUS. Lead researcher Carlos Collet from the Cardiovascular Research Foundation emphasized that CCTA-guided planning enables clinicians and patients to discuss treatment options, anticipated benefits, and procedural risks before catheterization, shifting critical planning decisions from the catheterization laboratory to pre-procedural imaging. This approach combines anatomical and physiological evaluation with intra-procedural guidance, potentially streamlining complex procedures despite increased use of advanced calcium-modification devices, ultimately expanding CCTA's clinical role beyond diagnosis.

Coronary calcium assessment requires intravascular imaging rather than angiography alone, which misses 30 to 40% of significant calcium. This article, part two of a three-part series on calcific coronaries management based on a Jivo Masterclass by Dr. Subhash Chandra from BLK-Max Super Speciality Hospital, explores the choice between intravascular ultrasound (IVUS) and optical coherence tomography (OCT). Both techniques are catheter-based and passed over the guide wire, but they offer distinct advantages. IVUS requires no contrast, while OCT provides higher resolution and measures calcium thickness. For OCT, specific thresholds indicate the need for intervention: a calcium arc exceeding 180 degrees, thickness above 0.5 millimeters, and length greater than 5 millimeters signal escalation to atherectomy or intravascular lithotripsy. Dr. Chandra emphasizes that intravascular imaging is essential before calcified intervention, as it reveals vessel wall calcium that angiography cannot detect. The critical distinction lies in selecting the appropriate imaging tool based on patient factors, particularly kidney function, to guide optimal treatment planning and device selection.

Chronic total occlusion (CTO), a complete coronary artery blockage lasting over three months, affects 15-25% of patients undergoing coronary angiography and represents a significant clinical challenge. CTOs cause refractory angina in up to 40% of patients, left ventricular dysfunction, increased mortality risk, and reduced quality of life. While revascularization aims to restore blood flow and improve myocardial perfusion, functional recovery remains inconsistent and unpredictable across patients. The critical clinical question centers on whether myocardium will recover function after revascularization, which depends on the presence of viable but dysfunctional tissue. Recovery mechanisms include myocardial viability, hibernation (reversible contractile dysfunction from reduced blood flow), and stunning (post-ischemic dysfunction despite restored perfusion). Currently, robust predictors of functional recovery are poorly defined, creating uncertainty in patient selection and procedural planning. Identifying comprehensive predictive models integrating mechanical, biological, and technical factors is essential to determine which patients will benefit most from CTO revascularization and optimize clinical outcomes.

Quantitative flow ratio (QFR) is a computational technique that analyzes coronary angiograms to determine whether arterial narrowing functionally impairs blood flow, eliminating the need for invasive pressure wires or hyperemic drugs. A prespecified secondary analysis of the FAVOR III China randomized trial, which enrolled 3,825 patients across 26 Chinese centers between December 2018 and January 2020, evaluated whether QFR-guided percutaneous coronary intervention (PCI) improved outcomes in patients with multivessel disease. Researchers led by Zhang compared QFR-guided treatment, where lesions with QFR values at or below 0.80 were treated while higher values were deferred, against angiography-guided treatment based on visual assessment alone. Among the analyzed population, 54 percent had multivessel disease. At three years, QFR-guided PCI demonstrated fewer major adverse cardiac events in multivessel disease patients; however, this finding was not statistically significantly different from those without multivessel disease. While the study demonstrates QFR's utility in refining lesion selection for intervention, it does not establish QFR equivalence to invasive fractional flow reserve or compare PCI versus coronary artery bypass grafting, leaving important clinical questions unresolved.

Researchers Zhang, Zhang, and Xie conducted a study examining the combined effects of lipoprotein(a) and hyperuricemia on long-term cardiovascular outcomes in patients with chronic total occlusion (CTO). Published in Frontiers in Endocrinology in 2026, this investigation explored how these two metabolic risk factors interact to influence major adverse cardiac and cerebrovascular events (MACCEs). The study focused on risk stratification by analyzing the joint association between elevated lipoprotein(a) levels and hyperuricemia—a condition characterized by high uric acid concentrations in the blood. Understanding these interactions is clinically significant because chronic total occlusion represents a complete blockage of coronary arteries, a serious condition requiring intervention. By identifying how lipoprotein(a) and hyperuricemia work together to affect patient outcomes, this research provides valuable insights for improved risk assessment and potentially more targeted therapeutic strategies in CTO management, ultimately helping clinicians better predict which patients face elevated risks of adverse cardiac events.

Percutaneous coronary intervention (PCI), developed in the 1970s, has evolved significantly and remains a cornerstone of acute coronary care. This comprehensive review synthesizes clinical trials and major cardiology guidelines to provide updated guidance for general physicians on PCI indications, timing, and device selection across diverse patient populations. For ST-elevation myocardial infarction (STEMI), PCI is recommended within 12 hours of symptom onset, with optimal door-to-balloon times of 90-120 minutes. Non-STEMI patients typically benefit from PCI during hospitalization, though early intervention may not advantage frail elderly patients. Complete revascularization is generally preferred over treating only culprit lesions, except in cardiogenic shock cases. For chronic coronary syndrome, while PCI improves symptom management and quality of life, most trials show it does not significantly reduce mortality or major cardiovascular events. The review addresses the evolution from plain old balloon angioplasty and its restenosis complications, emphasizing appropriate patient selection and device optimization to maximize clinical outcomes across varying presentations and risk profiles.

This retrospective observational study compared intravascular lithotripsy (IVL), an emerging technique, against the established standard rotational atherectomy (RA) for treating severely calcified coronary lesions in patients with tortuous or angulated coronary anatomy. Researchers analyzed 247 patients treated between January 2023 and March 2025, comprising 137 receiving RA and 110 receiving IVL. Using rigorous analytical methods including inverse probability of treatment weighting with gradient boosted modeling and doubly robust estimation, the study found that IVL was associated with a significant 52% reduction in major adverse cardiovascular events (MACE) at one year compared to RA. MACE encompassed all-cause mortality, target vessel revascularization, heart failure rehospitalization, in-stent restenosis, and stroke. Additionally, IVL demonstrated significantly lower heart failure rehospitalization rates. These findings suggest IVL may offer superior prognostic benefits over rotational atherectomy in real-world practice for this complex patient population, though longer-term prospective studies are warranted to confirm these encouraging preliminary results.

Researchers conducted a comprehensive meta-analysis comparing two drug-coated balloon technologies used in coronary disease treatment: sirolimus-coated and paclitaxel-coated balloons. Drug-coated balloons represent an innovative approach to preventing restenosis—the re-narrowing of coronary arteries following angioplasty—by delivering therapeutic agents directly to vessel walls during balloon inflation. This systematic review, published in BMC Cardiovascular Disorders in October 2026, synthesized evidence from multiple clinical trials to evaluate the comparative efficacy and safety profiles of these two distinct drug-eluting technologies. The analysis examines critical outcomes including restenosis rates, target lesion revascularization requirements, and adverse event profiles across patient populations. Understanding which drug-coated balloon technology delivers superior clinical outcomes matters significantly for interventional cardiologists and healthcare systems selecting treatment strategies. The findings provide evidence-based guidance for optimizing percutaneous coronary intervention protocols and improving long-term patient outcomes in coronary artery disease management.

Drug-coated balloons (DCBs) are emerging percutaneous coronary intervention devices that deliver antiproliferative agents directly to vessel walls without implanting permanent metallic scaffolds. This comprehensive review examines contemporary DCB technology and its expanding clinical applications across multiple coronary pathology scenarios. Modern DCB platforms primarily utilize paclitaxel- or sirolimus-coated technologies, with advances in carrier systems and coating techniques significantly improving drug transfer efficiency and long-term outcomes. Randomized trials support DCB use in in-stent restenosis and small-vessel coronary disease, though European guidelines currently favor repeat drug-eluting stent implantation for restenosis management. Evidence remains limited in bifurcation lesions, acute coronary syndromes, and chronic total occlusions, with the REC-CAGEFREE I trial demonstrating that DCB strategy did not achieve non-inferiority against DES in unrestricted de novo lesions. Appropriate lesion preparation and intravascular imaging integration are critical for procedural success. DCB technology represents an established component of the "leave nothing behind" strategy in selected indications, though adequately powered randomized trials with long-term clinical endpoints are needed to define its role in de novo settings.

The PIONEER IV trial, presented at TCT 2026, evaluated whether angiography-derived fractional flow reserve (angio-FFR) could improve outcomes compared to usual care in 2,130 patients undergoing percutaneous coronary intervention for various indications including chronic and acute coronary syndromes, NSTEMI, and STEMI. All participants received the HT Supreme drug-eluting stent and followed a standardized antiplatelet therapy regimen. The primary composite endpoint of all-cause mortality, stroke, myocardial infarction, and revascularization at one year occurred in 7.4% of the angio-FFR group versus 6.1% of usual care patients, failing to meet the prespecified noninferiority margin of 3.2%. However, a per-protocol analysis among adherent patients demonstrated noninferiority, with event rates of 5.5% versus 5.3% respectively. The elevated event rate in the intention-to-treat analysis was primarily driven by spontaneous nontarget-vessel NSTEMI related to nonadherence with angio-FFR guidance, underscoring the critical importance of protocol adherence in angio-FFR-guided PCI strategies.

The ICARE trial is a randomized controlled study comparing two cutting-edge calcified lesion debulking techniques for coronary interventions: rotational atherectomy using the Rotablator device and intravascular lithotripsy (IVL) using C2 Shockwave Medical's technology. The study will evaluate treatment efficacy by measuring final minimal stent area on Optical Frequency Domain Imaging following percutaneous coronary intervention with the ULTIMASTER TANSEI drug-eluting stent. Researchers hypothesize that both approaches will achieve comparable final stent areas in patients with highly calcified coronary lesions. The trial enrolls patients aged 18 and older with native coronary artery disease causing stable or unstable angina, requiring treatment of de novo lesions with moderate to severe calcification in major coronary arteries. Eligible lesions must measure 2.5–4.0mm in vessel diameter and not exceed 40mm in length. This comparison addresses a critical clinical challenge, as calcified lesions complicate stent deployment and increase restenosis risk, making effective debulking essential for optimal interventional outcomes.

Coronary angiography has traditionally guided percutaneous coronary intervention (PCI) decisions, but visual assessment of stenosis severity often misrepresents physiological significance. While fractional flow reserve (FFR) and nonhyperemic pressure ratios (NHPRs) have advanced revascularization strategies over two decades, they provide only binary ischemic assessments. Pullback pressure gradient (PPG) assessment represents a significant advancement, offering a dynamic, spatially resolved functional map of coronary artery disease by tracing pressure distribution along the vessel. Landmark trials including FAME and FAME 2 demonstrated FFR-guided PCI benefits, though strategies using instantaneous wave-free ratio (iFR by Philips) showed increased five-year major cardiovascular events compared to FFR guidance. PPG overcomes single-point measurement limitations by enabling visualization of pressure drop locations during sensor withdrawal from distal to proximal segments. The standardized PPG index quantifies pressure loss distribution objectively, distinguishing focal from diffuse disease patterns with improved reproducibility. This technique enables precise intervention planning for hemodynamically significant lesions while avoiding unnecessary stenting in diffuse disease cases.

A comparative study evaluated intravascular lithotripsy and rotational atherectomy, two minimally invasive techniques for treating heavily calcified coronary lesions that are difficult to treat with standard angioplasty. Intravascular lithotripsy uses acoustic pulse technology to fragment calcium deposits, while rotational atherectomy employs a rotating burr to ablate calcified plaque. The research analyzed the efficacy, safety, and clinical outcomes of both approaches in patient populations presenting with complex coronary artery disease. This comparison is clinically significant as calcified lesions remain a substantial challenge in percutaneous coronary intervention, often limiting successful stent deployment and optimal revascularization. By contrasting these two advancing technologies, the study provides interventional cardiologists with evidence-based guidance for selecting the most appropriate tool for individual patient cases. The findings contribute to optimizing treatment strategies for this high-risk subset of coronary patients, potentially improving procedural success rates and reducing adverse events related to inadequate lesion preparation.

Coronary artery calcification represents a critical challenge in percutaneous coronary intervention, significantly impacting procedural success and long-term patient outcomes. Calcium deposits obstruct device delivery, cause incomplete stent expansion, damage drug coatings, and increase risks of stent thrombosis, restenosis, and target-lesion revascularization. Contemporary management has evolved from angiography-based approaches toward morphology-specific strategies utilizing intravascular imaging technologies. Optical coherence tomography and intravascular ultrasound enable precise assessment of calcium characteristics including arc, thickness, length, and nodule presence. Validated imaging scores predict underexpansion and guide treatment selection. The expanded toolkit includes noncompliant, cutting, scoring, and super-high-pressure balloons; rotational and orbital atherectomy; intravascular lithotripsy; and excimer laser coronary atherectomy. Strategic combinations of these interventions optimize outcomes by addressing the specific morphological features identified through advanced imaging, fundamentally improving procedural efficacy and reducing adverse complications in calcified coronary lesions.

Coronary lesion functional assessment is essential for guiding percutaneous coronary intervention decisions, yet wire-based fractional flow reserve (FFR) adoption remains limited due to cost, complexity, and procedural demands. Angiography-derived physiological indices, particularly quantitative flow ratio (QFR), offer promising alternatives by eliminating the need for pressure wires and pharmacological hyperaemia induction while enabling virtual pullback analysis to distinguish focal from diffuse disease. QFR potentially expands physiology-guided revascularisation accessibility, especially in centers with low pressure wire utilization. The FAVOR III Europe trial's two-year follow-up, reported in EuroIntervention, provides crucial validation data examining whether QFR-guided revascularisation matches FFR-guided outcomes. This research represents more than a simple device comparison; it tests whether physiological assessment can be democratized across interventional laboratories without sacrificing patient outcomes. The trial's findings will significantly influence whether angiography-derived FFR becomes standard practice, potentially transforming how interventional cardiologists approach revascularisation planning globally.

Calcified coronary artery blockages present unique treatment challenges that require individualized assessment rather than standardized approaches. While some calcium deposits can be managed with conventional balloon angioplasty and stenting, severe or extensive calcification may necessitate advanced techniques and careful lesion preparation to ensure proper stent expansion. Treatment decisions consider multiple factors beyond calcium presence, including blockage severity and location, calcium pattern and amount, artery condition, patient symptoms, and heart function. Heavily calcified arteries become rigid, potentially preventing adequate balloon expansion and stent deployment. Intravascular imaging plays a crucial role in treatment planning, with IVUS using ultrasound technology and OCT employing light-based imaging to provide detailed vessel and calcium assessment. These techniques help cardiologists understand vessel characteristics and calcium distribution, enabling more precise treatment planning. The key distinction is that calcium alone does not automatically warrant advanced angioplasty; rather, treatment selection depends on whether calcium significantly interferes with balloon expansion or stent delivery in the specific patient's artery, ensuring optimal clinical outcomes.

Coronary bifurcation lesions represent a common clinical challenge in interventional cardiology, occurring frequently due to low wall shear stress in areas opposite the carina of bifurcations. This professional overview presents a comprehensive, step-wise approach to percutaneous coronary intervention in bifurcation lesions, with detailed discussion available in the complete e-version at EuroIntervention. The coronary tree follows fractal geometry principles, with bifurcations governed by Murray's law and Finet's formula, which establishes the diameter relationship between the main vessel and distal branches. The Medina classification serves as the primary descriptive tool for bifurcation lesions, indicating the location of significant stenosis greater than fifty percent across proximal main vessel, distal main vessel, and side branch segments. Among multiple treatment techniques encompassed in the MADS classification, provisional side branch stenting has emerged as the gold standard strategy for non-left main bifurcation treatment. Six of seven randomized trials comparing this approach with dual-stent techniques demonstrated that implanting two stents provides no additional benefits regardless of lesion type, establishing provisional side branch stenting as the preferred interventional strategy.

Researchers from multiple institutions across South Korea and Canada have developed a novel therapeutic approach to address a longstanding clinical challenge in stent-based vascular interventions. The study, published in Theranostics, tackles the inherent conflict between preventing restenosis and promoting healthy vascular healing following stent placement. Traditional drug-eluting stents effectively reduce neointimal hyperplasia by suppressing vascular smooth muscle cell proliferation, yet their cytostatic mechanisms inadvertently impede re-endothelialization and compromise the vessel's natural repair processes. This therapeutic tradeoff has limited clinical outcomes for patients undergoing revascularization procedures. The research team investigated a regenerative scaffold strategy designed to decouple restenosis prevention from the detrimental effects on vascular healing. By separating these competing biological demands through an innovative scaffold-based platform, the investigators aimed to maintain antirestenotic efficacy while simultaneously facilitating proper endothelial recovery and tissue repair. This advancement represents a significant step toward improving long-term outcomes in percutaneous coronary intervention by enabling both effective restenosis suppression and optimal vascular healing, potentially reducing restenosis rates and patient complications while maintaining the therapeutic benefits of current stent technologies.

Coronary bifurcation lesions are common in clinical practice due to low wall shear stress areas present in both branches opposite the carina. This professional overview presents a comprehensive step-wise approach to percutaneous coronary intervention (PCI) in bifurcation lesions, with particular emphasis on provisional side branch (SB) stenting as the gold standard technique. The article establishes anatomical context using Murray's law and Finet's formula, which define the diameter relationships between main vessels and distal branches according to principles of fractal geometry. The Medina classification is introduced as a descriptive tool for characterizing bifurcation lesions based on stenosis location, though it cannot account for angles, calcifications, or lesion length. The MADS classification summarizes various treatment techniques available for bifurcation intervention. Evidence from six of seven randomized trials demonstrates that provisional SB stenting outperforms dual-stent strategies regardless of lesion type, establishing it as the preferred approach for non-left main bifurcation treatment. The systematic analysis provided addresses the substantial ongoing debate regarding optimal technical strategies in bifurcation intervention and provides detailed guidance for interventional cardiologists managing these complex lesions.