Successful Recanalization of Chronic Total Occlusions Is Associated With Improved Long-Term Survival
What is the clinical impact of successful recanalization of coronary chronic total occlusions (CTOs)?
The authors evaluated the impact of CTO percutaneous coronary intervention (PCI) on 836 patients who were treated at a single center in London from 2003 to 2010. The study endpoint was all-cause mortality, and the median follow-up was 3.8 years. Patients were stratified into those with successful CTO or unsuccessful CTO recanalization.
PCI was successful in a total of 582 (69.6%) procedures. Stents were implanted in 97.0% of successful procedures and drug-eluting stents were used in 73%. Procedural complications, including coronary dissection, were more frequent in unsuccessful cases (20.5% vs. 4.9%; p < 0.0001), but there was no difference in in-hospital major adverse cardiac events (3% vs. 2.1%; p = not significant). All-cause mortality at 5 years was significantly higher in patients with failed recanalization (17.2% vs. 4.5%; p < 0.0001). The need for coronary artery bypass grafting was significantly lower following successful CTO PCI (3.1% vs. 22.1%; p < 0.0001). After adjusting for the differences in baseline variables, successful PCI of a CTO was independently associated with a lower mortality (hazard ratio, 0.32; 95% confidence interval, 0.18-0.58).
The authors concluded that successful PCI of a CTO is associated with a survival benefit.
The survival benefit of CTO PCI has been debated extensively in the literature, and this study does little to settle the debate. The magnitude of the mortality reduction seen in this observational study is exceedingly high, and exceeds that seen in any randomized trial in stable coronary artery disease. A CTO that can be recanalized is quite different compared with one that cannot be recanalized, and it is possible that the aggressive coronary artery disease seen in the latter group explains the difference in survival that was observed in this study. Until these findings can be verified in a randomized controlled trial, CTO PCI should be reserved for patients with lifestyle-limiting angina that cannot be adequately controlled with medical therapy.
Keywords: Coronary Artery Disease, Follow-Up Studies, Coronary Stenosis, London, Drug-Eluting Stents, Myocardial Revascularization, Confidence Intervals, Coronary Artery Bypass, Angioplasty, Percutaneous Coronary Intervention
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