Aorto‐Ostial Right Coronary Artery Chronic Total Occlusion Percutaneous Coronary Intervention: Technical Outcomes and Predictors of Failure From the ERCTO Registry

Background Aorto‐ostial chronic total occlusions (CTOs) of the right coronary artery (RCA) represent a particularly complex subset of CTO percutaneous coronary interventions (PCI), yet dedicated data remain limited. We aimed to evaluate technical outcomes of aorto‐ostial versus non–aorto‐ostial RCA CTO PCI and to identify predictors of failure in RCA aorto‐ostial lesions. Methods Patients undergoing RCA CTO PCI between 2016 and 2024 and enrolled in the ERCTO (European Registry of Chronic Total Occlusion) registry were included in the present analysis. The primary end point was technical success. Multivariable logistic regression was used to identify independent predictors of technical failure. Results A total of 26 374 patients undergoing RCA CTO PCI were included in the analysis, of whom 2850 had aorto‐ostial and 23 524 non–aorto‐ostial lesions. Technical success was lower in aorto‐ostial compared with non–aorto‐ostial lesions (79.6% versus 89.7%; P <0.001). Aorto‐ostial location was independently associated with technical failure (adjusted odds ratio [OR], 1.85; P <0.001). In multivariable analysis restricted to aorto‐ostial CTOs, stumpless proximal cap morphology (adjusted OR, 2.44, P <0.001), moderate‐to‐severe tortuosity (adjusted OR, 2.13 P <0.001), severe calcification (adjusted OR, 1.92, P <0.001), and peripheral artery disease (adjusted OR, 1.57 P <0.001) were independently associated with technical failure. In‐hospital major adverse cardiac and cerebrovascular events rates were low and did not differ significantly between groups. Conclusions Aorto‐ostial RCA CTO PCI has a significantly lower technical success despite extensive use of advanced techniques. Technical failure is driven primarily by lesion‐specific anatomical features, underscoring the need for dedicated strategies and refined risk stratification tailored to aorto‐ostial anatomy.