The association between the advanced lung cancer inflammation index and successful antegrade recanalization in patients with coronary chronic total occlusion: a retrospective cross-sectional study

BACKGROUND: Chronic total occlusion (CTO) represents one of the most challenging lesion subsets in coronary artery disease, and antegrade recanalization (AR) is the preferred approach for revascularization due to its lower complication risk. However, predicting AR success remains clinically difficult. The Advanced Lung Cancer Inflammation Index (ALI), integrating body mass index, albumin, and neutrophil-to-lymphocyte ratio, reflects nutritional and inflammatory status, both of which may influence procedural outcomes. This study aimed to investigate the association between ALI and successful AR in CTO patients undergoing percutaneous coronary intervention (PCI). METHODS: In this retrospective cross-sectional study, 198 patients with angiographically confirmed CTO undergoing PCI between May 2024 and December 2025 were analyzed. Patients were stratified into successful AR (n = 132) and failed AR (n = 66) groups based on the final recanalization route. ALI was calculated preprocedurally. Multivariable logistic regression, generalized additive modeling (GAM), and subgroup and sensitivity analyses were performed to examine the association between ALI and AR success. Receiver operating characteristic (ROC) curves were used to evaluate the predictive capability of ALI and the Japanese CTO Registry (J-CTO) score for successful AR, with DeLong' s test to compare model differences. Confusion matrix parameters were also used to assess model performance. RESULTS: Patients in the successful AR group had significantly lower ALI values than those in the failed group (P = 0.012). Higher ALI was independently associated with lower odds of AR success in both unadjusted (OR = 0.624; 95% CI, 0.437-0.859; P = 0.006) and fully adjusted models (OR = 0.622; 95% CI, 0.416-0.879; P = 0.013). GAM confirmed an approximately linear inverse relationship between ALI and AR success (P = 0.013). Subgroup analyses showed consistent associations across clinical strata, with particularly strong effects in males and patients with prior PCI or MI. Sensitivity analysis revealed a significant dose-response trend across ALI quartiles (P for trend = 0.021), with the highest ALI quartile associated with significantly lower AR success (OR = 0.318; 95% CI, 0.121-0.96; P = 0.017). ROC curve analysis demonstrated that ALI alone had fair predictive performance for AR success (AUC = 0.608; 95% CI, 0.524-0.692), with high specificity (0.970) but low sensitivity (0.106; F1 = 0.182). The J-CTO score improved discrimination (AUC = 0.760; 95% CI, 0.696-0.823), and combining ALI with J-CTO further enhanced predictive ability (AUC = 0.798; 95% CI, 0.736-0.860; sensitivity = 0.439, specificity = 0.864, F1 = 0.513). DeLong' s test confirmed a statistically significant AUC improvement for the combined model versus J-CTO alone (ΔAUC = 0.038; 95% CI, 0.007-0.069; P = 0.017), indicating additional prognostic value of ALI. CONCLUSIONS: ALI is independently and inversely associated with the success of AR in CTO lesions. As a composite biomarker of inflammation and nutrition, ALI may help identify patients with lower probability of AR success and, when combined with the J-CTO score, enhance preprocedural assessment and procedural planning.