Effectiveness of Chronic Coronary Total Occlusion PCI

Study Questions:

What is the contemporary incidence of chronic total occlusions (CTOs) and the success rates of CTO percutaneous coronary intervention (PCI), as well as the complications and long-term outcomes of these patients?

Methods:

The investigators examined consecutive veterans undergoing coronary angiography at 79 Veterans Affairs sites between 2007 and 2013. Detailed baseline clinical, angiographic, and follow-up outcomes were evaluated using national data from the Veterans Affairs Clinical Assessment Reporting and Tracking program. The authors used the Kaplan-Meier method to determine event-free survival and compared the two groups using the log-rank test, survival curves, and estimated survival rates at 1 and 2 years.

Results:

Among 111,273 patients with obstructive coronary artery disease, 29,399 (26.4%) had ≥1 CTO, most commonly in the right coronary artery distribution (n = 18,986 [64.6%]). Elective CTO PCI was attempted in 2,394 patients (8.1%), with a procedural success rate of 79.7%. The odds of CTO PCI success increased over the years of the study (odds ratio, 1.08; 95% confidence interval [CI], 1.01-1.16; p = 0.03). Compared with failed CTO PCI, successful CTO PCI was associated with a decreased adjusted risk for mortality (hazard ratio, 0.67; 95% CI, 0.47-0.95; p = 0.02) and coronary artery bypass graft surgery (CABG) (hazard ratio, 0.14; 95% CI, 0.08-0.24; p < 0.01) at 2 years, but no significant change in the risk for hospitalization for myocardial infarction (hazard ratio, 0.89; 95% CI, 0.58-1.36; p = 0.58).

Conclusions:

The authors concluded that approximately one in four patients with obstructive coronary artery disease on coronary angiography had CTOs, and that successful CTO PCI was associated with better outcomes.

Perspective:

This registry study reports that compared with patients with failed CTO PCI, successful CTO PCI was associated with improved survival at 2 years and a decreased likelihood for subsequent CABG procedures. It should be noted that as in all observational studies, unmeasured confounders that could influence the likelihood of CTO PCI success or failure were not considered. The DECISION-CTO randomized trial presented at ACC 2017 showed that routine CTO-PCI with optimal medical therapy is not superior to optimal medical therapy alone in reducing cardiovascular outcomes among patients, and failed to show benefit of CTO PCI.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Aortic Surgery, Cardiac Surgery and Arrhythmias, Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Nuclear Imaging

Keywords: Cardiac Surgical Procedures, Coronary Angiography, Coronary Artery Bypass, Coronary Artery Disease, Coronary Occlusion, Disease-Free Survival, Myocardial Infarction, Outcome Assessment (Health Care), Percutaneous Coronary Intervention, Secondary Prevention, Survival Rate, Veterans


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