Background: In cases of failed re-entry into the distal true lumen during chronic total occlusion (CTO) percutaneous coronary intervention (PCI), subintimal plaque modification to restore some antegrade flow may facilitate subsequent lesion recanalization (“investment procedure”). Methods: We examined the subsequent outcomes of 58 CTO PCI “investment procedures” of 4,657 CTO PCIs in total (1.2%) from a large, multicenter registry between years 2012 and 2019. Results: Mean patient age was 67 ± 9 years, and 86% were men. Patients had high prevalence of cardiovascular risk factors such as dyslipidemia (91%), hypertension (93%), and diabetes (48%); prior PCI (61%); and prior coronary artery bypass surgery (47%). The target CTO lesions were highly complex as illustrated by the high frequency of proximal cap ambiguity (54%), moderate/severe calcification (73%), moderate/severe tortuosity (63%), and high J-CTO score 3.2 ± 1.1. The rate of technical and procedural success achieved during subsequent CTO PCI was high (85% and 82%, respectively) with an acceptable rate of in-hospital major adverse cardiac events (3.3%). Median subsequent procedure time was 148 min (101, 221 min), median contrast volume was 188 ml (150, 262 ml), and median air kerma radiation dose was 2.5 Gy (1.4, 4.2 Gy) (Figure). [Figure presented] Conclusion: “Investment procedures” as bailout strategy in CTO PCI are associated with likelihood for successful revascularization during repeat CTO PCI attempt
