ORBITA-CTO, DKCRUSH VIII, and ECLIPSE

The blinded RCT the field has needed since the original ORBITA (2017). The OR 4.38 is large and the Bayesian Pr[Benefit]=0.996 leaves little room for doubt about direction. Critical caveats: n=50, strict single-vessel selection, no bystander disease, anti-anginals stopped — this is a best-case scenario population. The endpoint is symptom-driven, not MACE. Do not extrapolate to post-CABG, multi-vessel, or asymptomatic CTOs. The trial validates patient selection as the defining variable in CTO PCI — right patient, right result.

The largest effect size for IVUS vs. angiography in any complex PCI trial to date — TVF cut by 58%. The mechanism is well understood: IVUS catches incomplete expansion and malapposition at the carina and ostial SB after the crush, which angiography systematically misses. For any two-stent bifurcation strategy, IVUS guidance is no longer optional. This trial closes that debate.

First RCT-level evidence that imaging guidance specifically improves outcomes in severely calcified lesions — beyond the general complex PCI imaging literature. The heavier use of OCT vs. IVUS reflects calcium arc, depth, and fracture assessment advantages. Practical implication: after any calcium modification (rota, IVL, OA), imaging is mandatory before stenting. MSA targets and fracture confirmation are not optional in this lesion subset.