A B 90000 100 7 80000 5 84

A B 90000 100 7 80000 5. 84 60000 6 5. 71 Number of PCIs 5. 43 50000 5. 06 5 40000 4. 70 4. 33 30000 4. 29 4 20000 10000 0 47143 55475 63061 66106 68933 72274 76364 77765 3598 3587 3491 3394 3336 3303 3241 2840 2006 2007 2008 2009 CTO-PCI 2010 2011 2012 2013 3 Percent of CTO cases with femoral access 6. 02 CTO-PCI Percent of total PCI 70000 90 80 84. 6 80. 2 70 73. 2 69. 2 60 63. 6 59. 2 50 57. 3 57. 9 2012 2013 40 30 20 10 0 2006 2007 2008 2009 2010 2011 Total PCI Figure 1: A) Annual numbers of PCI, annual numbers of CTO-PCI, and percentage of total PCI represented by CTO-PCI in England Wales (p<0. 0001 for all annual trends); B) Annual rates of femoral puncture during CTO-PCI in England Wales 2006 -2013 (p<0. 0001 for trend).

A B 120% Percent of CTO cases with dual arterial access 100 90 100% 80 70 80% 60 50 60% 73. 0 40. 7 42. 0 41. 5 45. 0 51. 8 55. 3 48. 2 52. 8 63. 3 69. 9 83. 0 40 28. 7 30 23. 0 20 10 4. 1 5. 3 7. 7 8. 8 12. 4 40% 15. 6 20% 33. 8 24. 5 27. 4 0. 0 2. 5 2. 7 2. 9 6. 2 3. 3 6. 9 6. 6 2007 2008 2009 2010 2011 2012 2013 17. 0 0 2006 2007 2008 2009 2010 2011 2012 2013 0% Dual access wrist. Bi-radial Dual access Radial/femoral wrist/femoral Dual access Bifemoral Figure 2: A) Annual rates of dual arterial access use during CTO-PCI in England Wales 2006 -2013 (p<0. 0001 for trend); B) Annual rates of use of dual wrist access(p=0. 0045 for trend), dual wrist and femoral access(p=0. 0012 for trend), and dual femoral access (p=0. 0007) during CTO-PCI in England Wales 2006 -2013.

A B 77. 7 80 66. 2 70 60 60 82. 6 Percent of CTO cases with dual access Percent of CTO cases with femoral access 90 53. 0 50 40 30 20 10 0 52. 2 50 42. 5 40 32. 0 30 22. 4 20 10 0 0 1 2 CTO device use 3+ 0 1 2 3+ CTO device use Figure 3: A) Femoral access use by number of CTO device use (a combination of IVUS, penetration catheter, atherectomy, micro-catheter or Cross. Boss use) during CTO-PCI in England Wales 2012 -2013 (p=0. 001 for trend); B) Dual arterial access use by number of CTO device use during CTO-PCI(p=0. 0001 for trend).

Cumulative Incidence (%) 6 - No access site complication Access site complication 4. 4% [1. 8 -6. 9%] 4 - 2. 1% [2. 0 -2, 3%] 2 - 00 25578 255 1 25148 243 2 3 4 25105 25007 25029 243 242 5 24977 242 6 7 Month 24937 240 8 9 24903 24860 24820 240 239 10 24773 239 11 12 24742 24704 239 238 Figure 4: A) Kaplan Meier plots for 12 -month mortality by access site complication status in 2006 -2013 procedure years (p=0. 001).