Chronic Total Occlusion PCI and Survival
What is the long-term outcome of patients having percutaneous coronary intervention (PCI) of chronic total occlusions (CTOs)?
The investigators reported the outcome of 1,173 consecutive patients with CTO of native coronary vessels who underwent PCI between 2003-2014 at Asan Medical Center in Seoul, Korea. The procedure was successful in 1,004 patients (85%), and all of these were treated with a drug-eluting stent.
Over a median follow-up of 4.6 years, there was no difference in the adjusted risks of all-cause mortality (hazard ratio [HR], 1.04; 95% confidence interval [CI], 0.53-2.04; p = 0.92) and the composite of death or myocardial infarction (HR, 1.05; 95% CI, 0.56-1.94; p = 0.89) between those with successful versus failed attempt at PCI. The risk of target vessel revascularization (HR, 0.15; 95% CI, 0.10-0.25; p < 0.001) and coronary artery bypass grafting (CABG; HR, 0.02; 95% CI, 0.006-0.06; p < 0.001) was significantly lower in those with successful PCI of the CTO. The findings were consistent irrespective of completeness of revascularization or the presence of single versus multiple CTOs.
Successful PCI of a CTO is associated with a reduction in the need for CABG, but does not appear to provide a survival benefit.
There has been a significant increase in the number of patients having successful CTO PCI in recent years, even though there remains considerable controversy regarding the clinical benefit of this procedure. While there is no doubt that CTO PCI can be immensely beneficial in improving patient symptoms, the survival benefit of CTO revascularization is less clearly established. It had been previously argued that patients who underwent successful CTO PCI lived longer than those who failed CTO PCI, but in this study, there was no difference in the survival of these two groups. The ongoing DECISION-CTO trial will help answer this question, but in the interim, it is important that the procedure is offered for symptom relief rather than for prognostic reasons.
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