Percutaneous Coronary Intervention for Chronic Total Occlusion

Galassi AR, Brilakis ES, Boukhris M, et al.
Appropriateness of Percutaneous Revascularization of Coronary Chronic Total Occlusions: An Overview. Eur Heart J 2015;Aug 7:[Epub ahead of print].

The following are 10 points to remember from this overview on the appropriateness of percutaneous revascularization of coronary chronic total occlusions (CTOs):

  1. Coronary chronic total occlusions (CTOs) are commonly encountered in patients undergoing coronary angiography.
  2. Both European and American guidelines have assigned a Class IIa (Level of Evidence B) recommendation for CTO percutaneous coronary intervention (PCI).
  3. The assessment of quality of life is an important measure of the utility of revascularization in patients with coronary artery disease, and available evidence suggests a significant improvement in physical limitation, anginal episodes, and treatment satisfaction in successful versus failed CTO PCI patients.
  4. Discussing revascularization modalities and risk/benefit ratios in “patients with CTO,” in general, is an oversimplification, and decisions should be made based on the overall clinical presentation.
  5. CTOs can be encountered in vastly diverse clinical scenarios, such as elderly patients, presence of comorbidities, post–coronary artery bypass grafting, and normal or impaired left ventricular ejection fraction. These latter conditions should be considered in addition to the operator’s experience, in order to indicate the best management strategy for CTO patients.
  6. The performance of CTO PCI at facilities without on-site surgery is discouraged unless performed by expert CTO operators at a laboratory that has immediately available all interventional equipment needed for the procedure and the management of potential complications.
  7. Despite the paucity of randomized trials, one question arises in light of the recent technical advances in CTO revascularization, as to why the indication to treat a CTO by an expert operator should be considered any different from the one to treat other non-CTO lesions in stable angina, when symptoms and/or ischemia are present.
  8. It appears that there is no evidence to support that a CTO is less relevant with regard to clinical outcomes than for nonocclusive lesions.
  9. Results of ongoing randomized trials will provide additional insight into efficacy and safety of CTO PCI.
  10. Rational patient selection and operator experience will remain key factors to ensure procedural success and optimal outcomes.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Stable Ischemic Heart Disease, Aortic Surgery, Cardiac Surgery and SIHD, Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Nuclear Imaging, Chronic Angina

Keywords: Angina Pectoris, Angina, Stable, Coronary Angiography, Coronary Artery Disease, Coronary Occlusion, Myocardial Revascularization, Percutaneous Coronary Intervention, Quality of Life, Stroke Volume

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