Japanese researchers suggest that complex cases of chronic total occlusion (CTO) with bifurcation at the distal cap can be treated successfully using refined strategies, especially with use of the retrograde approach. The study, which analyzed data from 11,627 patients enrolled in the Japanese CTO-PCI Expert Registry, revealed that 2,462 cases (21.2%) involved bifurcations at the distal cap of the occluded artery, an anatomical feature previously thought to complicate procedures and lower success rates. “Bifurcation at the distal cap is often viewed as a barrier to successful intervention,” said the paper’s authors, led by Mayu Sakuma, MD, from the Cardiovascular Institute in Tokyo. “But our findings show that, with the appropriate approach, success is comparable to simpler cases.” Retrograde approach The retrograde approach involves navigating through small collateral vessels to reach the blockage from the far side and is used more frequently in bifurcation cases. The technique allows operators to bypass difficult entry points and approach the occlusion from behind, offering better access and visualization in complex anatomies. The study, published in the May 12 issue of JACC: Cardiovascular Interventions, revealed that the retrograde approach was used more frequently in cases with than without bifurcation (45.1% [n=1,111 of 2,462] versus 40.5% [n=3,716 of 9,165]; P<0.001). Analyzing each of the 3 major coronary vessels, the distal cap bifurcation group more frequently required the retrograde approach in the right coronary artery (57.7% [n=653 of 1,131] versus 49.4% [n=2,297 of 4,648]; P<0.001) and the left circumflex artery (28.4% [n=141 of 497] vs 23.7% [n=367 of 1,546]; P=0.044). No differences There were no significant differences in guidewire success, technical success or procedural success rates between the two groups. However, the bifurcation group required a longer procedure time, used more contrast volume and had a longer fluoroscopy time than the no bifurcation group. “Our data support current global CTO algorithms that recommend the retrograde strategy in bifurcation scenarios,” said the paper’s authors. “It’s a strong validation of the techniques expert operators have been refining for years.” Skill and strategy Commenting in an editorial, Dimitri Karmpaliotis, MD, from Cardiac Intervention Consultants in New York, and Darshan Doshi, MD, from Massachusetts General Hospital in Boston, highlighted that despite anatomical complexity, “procedural success... was similar for distal cap bifurcation and nonbifurcation lesions.” The authors stress the importance of operator skill and deliberate strategy, especially with increased use of the retrograde approach. “Anatomy alone should not dictate procedural avoidance,” the commentators said. Despite the recognized complexity, the experts added that no increase in major complications occurred. “However, distal cap bifurcation cases did have longer procedure times, greater contrast use and radiation exposure, and a higher rate of failed major side branch revascularization,” they said, noting the need for longer-term data. Methodology This prospective, non-randomized registry study analyzed 11,627 patients (mean age 67.7±11.1 years, 85.8% male) undergoing CTO-PCI in Japan. The primary endpoint was procedural success, defined as technical success without major adverse cardiac or cerebrovascular events. Bifurcation at the distal cap was evaluated for procedural impact. Sources: Sakuma M, Oikawa Y, Kishi K, et al. Outcomes of Percutaneous Coronary Intervention for Chronic Total Occlusion With Bifurcation at Distal Cap. JACC Cardiovasc Interv. 2025:18:1119–1130. Karmpaliotis D, Doshi D. A Fork at the End of the Road. JACC Cardiovasc Interv. 2025:18: 1131–1132. Image Credit: Wesley JvR/peopleimages.com – stock.adobe.com