This multicenter ( n = 12) retrospective observational study was conducted between January 2011 and June 2025 in Türkiye and involved 61 WCAA patients who underwent PCI or received GDMT. Patients received GDMT, including antianginal therapy and other prevention measures in accordance with the European Society of Cardiology guidelines. The major exclusion criteria were as follows: cardiogenic shock on presentation ( n = 1); end-stage hepatic disease ( n = 1); PCI with a bare metal stent ( n = 1); spontaneous coronary dissection ( n = 44); recanalized thrombus formation ( n = 2); bridging collaterals ( n = 24); patients with clinical follow-up of <3 months ( n = 8), and absence of all medical records ( n = 4). Patients who underwent PCI by low-volume operators ( n = 2) were also excluded from the study. The flow chart and patient selection are summarized in Figure 1 . At all institutions, the heart team, including consultant interventional cardiologists and cardiovascular surgeons, reviewed all treatment strategies (PCI, GDMT, or surgery), considering the current cardiovascular guidelines, the operator’s skills, and institutional experience. In this study, the operators’ decision to revascularize patients with WCAAs was based on the following indications: 1) TIMI flow grade <3 in the WCAA-related vessel; 2) symptomatic patients with reversible ischemia involving >10% of the WCAA territory; 3) complexity and anatomical features of the coronary artery disease (i.e., high SYNTAX [Synergy between PCI with Taxus and Cardiac Surgery] score); and 4) patient or referring physician preferences. Since no patients with WCAA underwent surgical revascularization during the study period, the study cohort was divided into 2 groups based on treatment strategy (PCI or GDMT). This study followed the Declaration of Helsinki guidelines and was approved by the Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital Institutional Ethics Committee (approval number# 2025.08-95). Owing to the retrospective design, informed consent was waived. The data that support the findings of this study are available from the corresponding author upon reasonable request.

Flow chart of the study. GDMT = guideline-directed medical therapy; PCI = percutaneous coronary intervention.

All patients were diagnosed with WCAA after conventional coronary angiography and confirmation by intravascular imaging if clinically indicated. ^, Recanalized thrombus formation, chronic total occlusion with bridging collaterals, and spontaneous coronary dissection were distinguished using intravascular imaging tools when necessary. ^,,,, The study included procedures performed by high-volume complex PCI operators because cases (limited number) performed by low-volume complex PCI operators at the study centers could affect the study results. ^,, Woven coronary stenting ( Figure 2 , Videos 1 – 4 ) with dedicated guidewires and microcatheters was performed following the current consensus report and expert opinions. ^,,, All patients underwent predilation with a 1:1 noncompliant balloon before stent implantation. Second- or third-generation drug-eluting stents (DES) were used in all PCI procedures. The stent size was selected according to the diameter of the distal portion of the target vessel. Stent optimization was routinely performed after stent deployment using a noncompliant balloon sized to the proximal target vessel with or without intravascular imaging. In some cases, PCI was performed under intravascular ultrasound (IVUS) guidance according to operator preference. When IVUS was used, it was performed in accordance with contemporary guidelines, utilizing dedicated IVUS catheters and automated pullback systems. To minimize variability, all IVUS measurements were repeated, and the average of 2 measurements was used in the final analysis. Routine pre and poststenting measurements were recorded systematically. All IVUS images were transferred to the high-volume tertiary heart center (Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital). Angiographic lesion characteristics of the WCAA and IVUS images were examined by 2 independent cardiologists with >5 years of experience in IVUS, who were unaware of the patient’s clinical condition. IVUS images were analyzed by operators at each center in accordance with the Japanese Society for Cardiovascular Intervention and Treatment Consensus Document. The lumen, external elastic membrane, and plaque measurements were automatically detected along the entire coregistered segment selected for analysis, and manually adjusted whenever necessary. Lesion length measurements by IVUS were performed using a motorized transducer pullback system (number of seconds × pullback speed). Alternatively, longitudinal imaging was used. Woven anomaly was defined as additional lumens separated by fibrous tissue, which was outside the tunica media, connecting to the distal lumen of the main vessel. Each tunnel contained a relatively complete 3-layer vascular structure. Post-PCI, stent area, stent expansion, minimum stent diameter, and maximum stent diameter were assessed in accordance with the Japanese consensus report. All conventional angiography images were assessed in the central core laboratory, where a 2-dimensional angiography measurement was performed retrospectively offline using automated software (syngo QCA, Siemens Healthineers, Munich, Germany). Measurements were performed on image sequences adequately filled with contrast, and when the vessel was not foreshortened. Calibration was performed on the contrast-filled segment of the guiding catheter. Measurements were performed on the lesion of interest using the automated software. Proximal and distal reference diameters were measured manually to determine the diameter of the normal segment of the vessel. Antiplatelet therapy and additional prevention medications (antianginal, statins, calcium channel blockers, angiotensin-converting enzyme inhibitors, beta-blockers) were prescribed according to current major cardiovascular guidelines. ^,,

Right anterior oblique cranial angiographic images show a woven coronary anomaly from the proximal segment to the distal part of the LAD artery with TIMI flow grade 3 (A). Intravascular ultrasound image demonstrates that 4 extra lumens (asterisks) are outside the vascular lumen (B). Final angiographic result after successful DES implantation (C). Right caudal angiographic images depicts a woven coronary anomaly from the proximal segment to the distal part of the RCA with TIMI flow grade 3 (D). Intravascular ultrasound image shows that two extra lumens (asterisks) are outside the vascular lumen (E). Final angiographic result after successful DES implantation (F). DES = drug-eluting stent; LAD = left anterior descending; RCA = right coronary artery; TIMI = thrombolysis in myocardial infarction.

The procedure time was defined as the time interval between the first guidewire placement and the final balloon inflation or deflation during PCI related to the target lesion. SYNTAX score was calculated using the validated online calculator, considering all angiographically significant coronary lesions, including lesion location, morphology, bifurcation involvement, total occlusions, and calcification. Contrast-induced acute kidney injury was defined as any of the following within 48 to 72 hours after contrast exposure: (a) an increase in serum creatinine by ≥26.4 µmol/L (0.3 mg/dL); (b) a relative increase of ≥1.5 to 1.9 times baseline creatinine; (c) urine output reduction to <0.5 mL/kg/h for >6 hours. All-cause/cardiac death, target vessel revascularization, target-vessel MI, spontaneous MI, stent thrombosis, target lesion revascularization, major bleeding, and stroke were defined according to the Academic Research Consortium-2. Rehospitalization for angina pectoris was defined as the need for hospitalization or coronary angiography due to objective evidence of myocardial ischemia on echocardiographic stress testing, myocardial perfusion imaging, or acute coronary syndrome such as unstable angina pectoris. The primary endpoint was defined as a major adverse cardiac event (MACE) and was the composite of cardiac death, target-vessel MI, target vessel revascularization, or rehospitalization for angina pectoris during follow-up. The secondary endpoint (hard endpoint) was defined as the combination of all-cause death or target-vessel MI.

Clinical data were obtained retrospectively through outpatient visits or medical records from the hospital database. Additionally, patients were contacted by telephone to confirm whether any endpoints had developed. The control invasive coronary angiography was retrospectively confirmed to have been performed in symptomatic patients or those with objective evidence of ischemia. Patients’ vital status was further verified through the National Death Database.

Descriptive statistics were reported using mean ± standard deviation for continuous variables with normal distribution, median values (25th to 75th percentiles) for continuous variables without standard distribution, and frequency with percentages for categorical data. The normality of the distribution of continuous variables was determined by Shapiro-Wilk and Kolmogorov-Smirnov tests. Where appropriate, Student’s t -test or Mann-Whitney U-test was performed to compare continuous variables between groups. Chi-square and Fisher’s exact tests were used to compare categorical variables.

To account for treatment selection bias, the Cox proportional hazard regression model for midterm primary and secondary endpoints were adjusted using the inverse probability weighted (IPW) approach to account for treatment selection bias. Hazard ratios (HR) with 95% confidence intervals (CI) were reported. A multivariable model was not constructed because of the small sample size, as it would lead to statistically unreliable results. Additionally, we did not select “presentation with chronic coronary syndrome, left ventricle ejection fraction, SYNTAX score, TIMI flow grade <3, lesion length” in the IPW-Cox regression model due to matching these parameters for baseline difference ( Figure 3 ). The Kaplan-Meier survival test was performed to calculate the cumulative incidences of primary (MACE) and secondary endpoints (death or MI), and they were compared between the groups using log-rank tests. The significance level was considered p < 0.05 in all statistical analyses. The R software v. 4.2.2 (R statistical software, Institute for Statistics and Mathematics, Vienna, Austria) was used for all statistical analyses.

The standardized variable differences (Covariate balance before and after Inverse probability-weighted). CCS = chronic coronary syndrome; IPW = inverse probability weighting; LV = left ventricle; TIMI = thrombolysis in myocardial infarction; SYNTAX = synergy between PCI with taxus and cardiac surgery.

This multicenter study included 61 consecutive WCAA patients [male: 52 (85%), mean age: 56.27 ± 9.89 years], and 31 patients (51%) were in the GDMT group, and 30 cases (49%) were in the PCI group ( Table 1 ). The MACE rate was 12% across a mean follow-up of 19.65 ± 13.84 months. Baseline demographic, clinical, and lesion characteristics are presented in Table 1 . The rate of antiplatelet drug usage (p = 0.042 for acetylsalicylic acid, clopidogrel p < 0.001, and p = 0.011 for ticagrelor), SYNTAX score (18.45 ± 6.75 vs 10.74 ± 5.29, p < 0.001), lesion length (46.60 ± 16.44 vs 36.55 ± 14.36 mm, p = 0.014), and frequency of TIMI flow grade <3 (40% vs 0%, p < 0.001) were notably higher in the PCI group compared to the GDMT group ( Table 1 ). Whereas, the rate of antianginal medication usage (23% vs 52%, p = 0.034) was significantly lower in the PCI group than in the GDMT group ( Table 1 ). The most common localization of WCAA was the right coronary artery (57%), followed by the left circumflex artery (20%), and the left anterior descending artery (20%), and there were no significant differences between the 2 groups.

Procedural details of the PCI group are shown in Table 2 . The mean procedure time was 61.67 ± 24.67 min, and the angiographic success rate was 97%. The WCAA was diagnosed in 24 (39%) out of 61 patients by intravascular imaging, which mainly IVUS. In the PCI group, the diagnosis was made in 50% of patients by intravascular imaging ( Table 2 ). Successful wiring was achieved in 12 patients with the Fielder XT-R (Asahi Intecc CO Ltd., Aichi, Japan), 8 with the Gladius MG (Asahi Intecc CO Ltd., Aichi, Japan), 3 with the Sion Black (Asahi Intecc CO Ltd., Aichi, Japan), 3 with Gaia 2/3 (Asahi Intecc CO Ltd., Aichi, Japan), 3 with the Pilot 150/200 (Abbot Comp., Abbott Park Road Abbott Park, IL, USA), and 1 with the Conquest Pro 12 (Asahi Intecc CO Ltd., Aichi, Japan) ( Table 2 ). Microcatheters were used in 19 of 30 patients who underwent PCI. Second- or third-generation DES was used in 29 cases, and DCB was used in only one case ( Table 2 ). No in-hospital death, spontaneous MI, major bleeding, or stroke occurred, except for one patient who developed contrast-induced acute kidney injury.

Table 2

Procedural characteristics of the PCI group

Parameters	PCI group ( n = 30)
Access site, n (%)
Femoral	24 (80%)
Radial	6 (20%)
Guiding catheter, n (%)
Judkins left	3 (10%)
Extra-backup	10 (33%)
Judkins right	8 (27%)
Amplatz left	10 (33%)
Antegrade approach, n (%)	29 (97%)
Performed intravascular imaging, n (%)	15 (50%)
Dedicated GW types for successful wiring, n (%)
Fielder XT-R	12 (40%)
Gladius MG	8 (27%)
Sion black	3 (10%)
Gaia 2/3	3 (10%)
Pilot 150/200	3 (10%)
Conquest Pro 12	1 (3.3%)
Total GW number	2.57 ± 0.73
Utilization of microcatheter, n (%)	19 (63%)
Predilatation, n (%)	30 (100%)
Performed DCB, n (%)	1 (3.3%)
Stent implantation
Stent number, n	1.87 ± 0.82
Stent diameter, mm	3.22 ± 0.41
Stent length, mm	51.45 ± 17.96
Drug-eluting stent brand, n (%)
Xience	4 (13%)
Promus	5 (17%)
Firehawk	17 (57%)
Resolute Onyx	3 (10%)
Postdilatation, n (%)	28/29 (97%)
Postdilatation balloon diameter, n (%)	3.74 ± 0.42
Intraprocedural complication, n (%)
Abrupt occlusion	1 (3.3%)
TIMI <3	2 (6.7%)
Dissection (> type B)	2 (6.7%)
Thrombus formation	1 (3.3%)
Coronary perforation	0 (0%)
Procedure time, min	61.67 ± 24.67
Fluoroscopy time, min	23.83 ± 10.57
Contrast media volume (mL)	273.67 ± 108.33
Angiographic success, n (%)	29 (97%)
In-hospital complications, n (%)
Death	0 (0%)
Spontaneous MI	0 (0%)
Major bleeding	0 (0%)
Stroke	0 (0.0%)
Contrast-induced AKI	1 (3.3%)

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