# Role of Femoral Artery Access Characteristics and Female Sex in In-Hospital Complications for Patients Undergoing Recanalization of Chronic Total Occlusions

## TL;DR

Women undergoing a complex heart procedure face higher complication risks, likely due to differences in their femoral artery anatomy.

## Contribution

The study identifies femoral artery characteristics as key predictors of complications in women undergoing CTO PCI.

## Key findings

- Female patients had smaller femoral artery diameters and more side branches, leading to higher complication rates.
- Adjusting for femoral artery metrics eliminated the independent risk of female sex for complications.
- Maximal femoral artery diameter and side-branch density were strong predictors of in-hospital complications.

## Abstract

Background: Percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) remains a complex procedure that requires advanced operator skills and dedicated devices. Despite increased success rates in experienced centers, the in-hospital complications of CTO PCI remain notably high. Female patients undergoing CTO PCI are reported to experience higher rates of complications; however, the underlying mechanisms remain inadequately defined. Methods: We prospectively enrolled consecutive patients undergoing CTO PCI at our university-affiliated tertiary care center over 4 years (2018–2021), aiming to elucidate sex-based disparities in in-hospital complications. In addition, we investigated the impact of angiographic femoral artery metrics on in-hospital complications. Results: Among 271 patients who underwent antegrade or retrograde CTO PCI, 222 (81.9%) were men and 49 (18.9%) women. Female patients were significantly older (67 ± 11 vs. 72 ± 12 years; p = 0.005) and had a comparable lesion complexity. Women exhibited smaller femoral artery diameters, more side branches at the puncture area and higher bifurcations. In-hospital complications occurred more frequently in women compared to men (16.3% vs. 6.8%; p = 0.044). Female sex independently predicted in-hospital complications (OR = 2.92; CI 1.07 to 7.60; p = 0.024), yet lost significance after adjustment for femoral artery characteristics. Maximal femoral artery diameter (OR = 0.30, 95% CI: 0.17 to 0.50, p < 0.001) and side-branch density (OR = 2.45, 95% CI: 1.26 to 5.20, p = 0.012) independently predicted in-hospital complications. Conclusions: Female patients undergoing CTO PCI are at increased risk for procedural complications, likely driven by femoral artery anatomical differences. Detailed pre-procedural assessment of femoral artery metrics may improve patient selection, procedural planning, and outcomes, particularly among women.