BMJ Open. 2026 Sep 28;16(9):e119900. doi: 10.1136/bmjopen-2026-119900.
ABSTRACT
BACKGROUND: Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is known for higher adverse event rates compared with non-CTO PCI. Comparative outcomes with respect to bleeding events remain limited.
OBJECTIVES: To evaluate bleeding events in patients undergoing CTO PCI compared with non-CTO PCI and to identify patient and procedural characteristics associated with bleeding events.
DESIGN AND SETTING: Prospective multicentre study of ongoing collected data registered within the South-East Netherlands Heart Registry (Zuid-Oost Nederland Hart Registratie, ZON-HR).
PARTICIPANTS: All consecutive patients with coronary artery disease undergoing clinically indicated PCI are included in the ZON-HR since November 2020.
RESULTS: At the time of analyses, the ZON-HR consisted of 8264 included patients with 30-day follow-up between November 2020 and December 2023. A total of 8162 patients were included once in the registry. CTO PCI was performed in 410 (5.0%) patients and non-CTO PCI in 7854 (95.0%) patients. Bleeding events occurred more frequently in patients undergoing CTO PCI compared with non-CTO PCI (9.0% vs 5.4%, p<0.01), driven by a significantly higher rate of access-site bleeding events (7.6% vs 3.2%, p<0.01). After multivariable analysis, CTO was not significantly associated with the occurrence of access-site bleeding events (adjusted HR (aHR) 1.39 (95% CI 0.92 to 2.11)). Access-site bleeding events were associated with female sex (aHR 1.71 (95% CI 1.34 to 2.18)), peripheral artery disease (aHR 1.39 (95% CI 1.02 to 1.89)), oral anticoagulation use (aHR 1.34 (95% CI 1.00 to 1.78)), femoral artery access (aHR 2.90 (95% CI 2.08 to 4.05)) and left main PCI (aHR 1.50 (95% CI 1.04 to 2.14)).
CONCLUSIONS: The incidence of bleeding events is higher in patients undergoing CTO PCI and particularly driven by access-site bleeding events. The apparent correlation is attributed to non-modifiable and modifiable patient-related and procedure-related characteristics rather than the CTO PCI itself.
TRIAL REGISTRATION NUMBER: NCT06512493.
PMID:42805651 | DOI:10.1136/bmjopen-2026-119900