Association Between Menopause Duration and Lesion Complexity in Chronic Total Occlusion: An Evaluation Using the Japanese-Chronic Total Occlusion Score

Objective: The decline in estrogen levels in menopause accelerates atherosclerosis through endothelial dysfunction, inflammation, and metabolic alterations. This process may contribute to increased cardiovascular risk in the postmenopausal period and to the development of more advanced coronary lesions. The J-CTO score is a widely used tool for assessing chronic total occlusion (CTO) lesion complexity and predicting procedural success. This study aimed to evaluate the association between menopause duration and CTO lesion complexity using the Japanese CTO (J-CTO) score. Methods: This retrospective observational study included 60 postmenopausal women with known menopausal status who underwent percutaneous coronary intervention for CTO at a tertiary center between January 2021 and December 2025. Patients were categorized into two groups according to J-CTO score: Low complexity (J-CTO <2) and high complexity (J-CTO ≥2). Demographic, clinical, laboratory, and angiographic data were obtained from hospital records. Missing data regarding menopausal age, duration of menopause, and obstetric history were completed by telephone interviews. The relationship between menopausal characteristics and J-CTO score was evaluated. Results: Of the 60 patients included in the study, 32 (53.3%) had low-complexity CTO lesions and 28 (46.7%) had high-complexity CTO lesions. There were no significant differences between the groups in age, body mass index, menopausal age, duration of menopause, or parity (p>0.05). Although menopause duration tended to be longer in the high-complexity group, the difference did not reach statistical significance (20.5 vs. 15, p=0.094). The high-complexity group had significantly higher rates of diabetes mellitus (p=0.039), hyperlipidemia (p=0.031), previous coronary artery disease (p=0.007), and prior CABG (p=0.034). Hemoglobin levels were lower (p=0.038), while urea and creatinine levels were higher p<0.001), and glomerular filtration rate was lower (p<0.001) in the high-complexity group. Angiographically, CTO length >20 mm (p=0.006), presence of calcification (p=0.048), and blunt stump morphology (p=0.012) were more frequent in the high-complexity group. Procedural success was significantly lower in the high-complexity group (p=0.041). Correlation analysis showed no significant association between menopausal age or menopause duration and J-CTO score. Conclusion: In this cohort of women with CTO, menopausal age and menopause duration were not significant determinants of CTO lesion complexity. Rather, lesion complexity was more closely associated with traditional cardiovascular risk factors, impaired renal function, and adverse angiographic characteristics. Although our study did not demonstrate a statistically significant association between menopause duration and CTO lesion complexity, the observed trend toward longer menopause duration in the high-complexity group may still be clinically relevant.