{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,28]],"date-time":"2026-09-28T17:56:51Z","timestamp":1790618211894,"version":"4.1.0"},"reference-count":26,"publisher":"BMJ","issue":"9","license":[{"start":{"date-parts":[[2026,9,27]],"date-time":"2026-09-27T00:00:00Z","timestamp":1790467200000},"content-version":"unspecified","delay-in-days":26,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"DOI":"10.13039\/100004339","name":"Sanofi","doi-asserted-by":"publisher","award":["Unrestricted grant, no grant number"],"award-info":[{"award-number":["Unrestricted grant, no grant number"]}],"id":[{"id":"10.13039\/100004339","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100001003","name":"Boehringer Ingelheim","doi-asserted-by":"publisher","award":["Unrestricted grant, no grant number"],"award-info":[{"award-number":["Unrestricted grant, no grant number"]}],"id":[{"id":"10.13039\/100001003","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100004325","name":"AstraZeneca","doi-asserted-by":"publisher","award":["Unrestricted grant, no grant number"],"award-info":[{"award-number":["Unrestricted grant, no grant number"]}],"id":[{"id":"10.13039\/100004325","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2026,8,13]]},"published-print":{"date-parts":[[2026,9]]},"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is known for higher adverse event rates compared with non-CTO PCI. Comparative outcomes with respect to bleeding events remain limited.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>To evaluate bleeding events in patients undergoing CTO PCI compared with non-CTO PCI and to identify patient and procedural characteristics associated with bleeding events.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design and setting<\/jats:title>\n                    <jats:p>Prospective multicentre study of ongoing collected data registered within the South-East Netherlands Heart Registry (Zuid-Oost Nederland Hart Registratie, ZON-HR).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Participants<\/jats:title>\n                    <jats:p>All consecutive patients with coronary artery disease undergoing clinically indicated PCI are included in the ZON-HR since November 2020.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>At the time of analyses, the ZON-HR consisted of 8264 included patients with 30-day follow-up between November 2020 and December 2023. A total of 8162 patients were included once in the registry. CTO PCI was performed in 410 (5.0%) patients and non-CTO PCI in 7854 (95.0%) patients. Bleeding events occurred more frequently in patients undergoing CTO PCI compared with non-CTO PCI (9.0% vs 5.4%, p&lt;0.01), driven by a significantly higher rate of access-site bleeding events (7.6% vs 3.2%, p&lt;0.01). After multivariable analysis, CTO was not significantly associated with the occurrence of access-site bleeding events (adjusted HR (aHR) 1.39 (95% CI 0.92 to 2.11)). Access-site bleeding events were associated with female sex (aHR 1.71 (95% CI 1.34 to 2.18)), peripheral artery disease (aHR 1.39 (95% CI 1.02 to 1.89)), oral anticoagulation use (aHR 1.34 (95% CI 1.00 to 1.78)), femoral artery access (aHR 2.90 (95% CI 2.08 to 4.05)) and left main PCI (aHR 1.50 (95% CI 1.04 to 2.14)).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>The incidence of bleeding events is higher in patients undergoing CTO PCI and particularly driven by access-site bleeding events. The apparent correlation is attributed to non-modifiable and modifiable patient-related and procedure-related characteristics rather than the CTO PCI itself.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Trial registration number<\/jats:title>\n                    <jats:p>\n                      <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"clintrialgov\" xlink:href=\"NCT06512493\">NCT06512493<\/jats:ext-link>\n                      .\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2026-119900","type":"journal-article","created":{"date-parts":[[2026,9,28]],"date-time":"2026-09-28T17:00:43Z","timestamp":1790614843000},"page":"e119900","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Bleeding complications after percutaneous coronary intervention of CTO lesions versus non-CTO lesions: a prospective observational study from the South-East Netherlands Heart Registration (ZON-HR)"],"prefix":"10.1136","volume":"16","clinical-trial-number":[{"clinical-trial-number":"nct06512493","registry":"10.18810\/clinical-trials-gov"}],"author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-7110-2934","authenticated-orcid":false,"given":"Alexander M","family":"Griffioen","sequence":"first","affiliation":[{"name":"Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5121-6109","authenticated-orcid":false,"given":"Eva C I","family":"Woelders","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sanne","family":"Janssen","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Zuyderland Medical Centre Heerlen, Heerlen, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Denise A M","family":"Peeters","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mustafa","family":"Ilhan","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Maastricht University Medical Centre+, Maastricht, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jasper J P","family":"Luijkx","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Zuyderland Medical Centre Heerlen, Heerlen, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mohamed M","family":"Reda","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands"},{"name":"Department of Cardiology, Assiut University Hospital, Assiut, Egypt"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Patty J C","family":"Winkler","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Zuyderland Medical Centre Heerlen, Heerlen, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marleen H","family":"van Wely","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Peter","family":"Damman","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wouter S","family":"Remkes","sequence":"additional","affiliation":[{"name":"Department of Cardiology, VieCuri Medical Centre, Venlo, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2344-7564","authenticated-orcid":false,"given":"Arnoud W J","family":"van\u2019t Hof","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Maastricht University Medical Centre+, Maastricht, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2943-5932","authenticated-orcid":false,"given":"Robert-Jan M","family":"van Geuns","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,9,28]]},"reference":[{"key":"2026092810002241000_16.9.e119900.1","unstructured":"Hafeez Y , Varghese V . 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