Meta-Analysis of Effect on Mortality of Percutaneous Recanalization of Coronary Chronic Total Occlusions Using a Stent-Based Strategy

Study Questions:

What is the survival impact of successful recanalization of chronic total occlusions (CTOs)?

Methods:

The authors performed a systematic review and a meta-analysis evaluating the all-cause mortality outcomes of successful percutaneous coronary intervention (PCI) for CTOs with unsuccessful CTO-PCI, using a stent-based strategy.

Results:

The authors identified 13 studies that met their inclusion criteria. A significantly lower short-term mortality (<30 days) was noted with successful CTO-PCI compared to unsuccessful CTO-PCI (odds ratio [OR], 0.218; 95% confidence interval [CI], 0.095-0.498; Z = -3.61; p < 0.001). There was a significant reduction in long-term mortality among those with successful CTO-PCI compared to unsuccessful CTO-PCI (OR, 0.391; 95% CI, 0.311-0.493; Z = -7.957; p < 0.001). A significant inverse association was present between coronary perforation and successful CTO-PCI (OR, 0.168; 95% CI, 0.104-0.271; Z = -7.333; p < 0.001).

Conclusions:

The authors concluded that patients with successful CTO PCI have a lower short-term and long-term mortality compared with those with unsuccessful CTO PCI.

Perspective:

The magnitude of the survival benefit of CTO PCI (e.g., the nearly 60% 1-year difference in this analysis) demonstrated in many observational studies is so extreme that it belies biological plausibility. While these studies have been used to argue for CTO recanalization, residual confounding and the possibility of harm in association with unsuccessful procedures cannot be ruled out. Indeed, that is probably the main reason for the observed difference in short-term outcomes. There is considerable debate on the survival benefit of CTO PCI, but in the absence of randomized data, CTO PCI should be performed only for symptom relief.

Clinical Topics: Invasive Cardiovascular Angiography and Intervention

Keywords: Stents, Percutaneous Coronary Intervention


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