A 43-year-old male presents for worsening angina and dyspnea on exertion and pre-operative cardiac evaluation prior to spinal surgery. His history is notable for a prior myocardial infarction. At that time the right coronary artery (infarct related artery) was treated with PCI with a drug eluting stent and a chronic total occlusion (CTO) of the mid left anterior descending (LAD) artery was identified. His other risk factors include hypertension, hyperlipidemia, diabetes mellitus type 2 and tobacco use. He underwent stress echocardiography that demonstrated hypokinesis along the left anterior descending artery distribution and left ventricular ejection fraction at rest of 55%. A subsequent coronary angiography demonstrated an occluded mid left anterior descending artery (LAD) with significant filling via right to left collaterals and patent right coronary artery stent. He was referred for evaluation for coronary artery pass surgery (CABG), but patient declined.
During the current presentation, he reports daily exertional class CCS III angina with progressive worsening despite maximal medical therapy.
Blood pressure was 118/70, heart rate 80 and body mass index 26 kg/m2. Physical exam was otherwise unremarkable.
After discussion with patient, a decision was made to proceed with proceed with percutaneous revascularization of the mid LAD CTO. As demonstrated in the video clips (Video 1, Video 2), a successful complex percutaneous coronary intervention (PCI) was performed with excellent results.
Video 1
Video 2
Which of the following is true regarding coronary chronic total occlusions and percutaneous revascularization of CTOs?
Show Answer
The correct answer is: D. Successful CTO PCI may be associated with improved long-term survival
Explanation:
Coronary chronic total occlusions are quite prevalent in patients undergoing coronary angiography, encountered in 18.4% to 52%.1-4 However, PCI of CTOs represents only 3.8% of all total PCI volume for stable coronary artery disease according to the recent National Cardiovascular Data Registry analysis from 2009 to 2013.5 Observational studies have showed benefits of successful CTO PCI, including improved angina symptoms, reduced referral for CABG and improved long-term survival;6, 7 however, randomized clinical trials are needed to confirm these findings.
References
Fefer P, Knudtson ML, Cheema AN, et al. Current perspectives on coronary chronic total occlusions: the Canadian Multicenter Chronic Total Occlusions Registry. J Am Coll Cardiol 2012;59: 991–7.
Christofferson RD, Lehmann KG, Martin GV, Every N, Caldwell JH, Kapadia SR. Effect of chronic total coronary occlusion on treatment strategy. Am J Cardiol 2005;95:1088–91.
Werner GS, Gitt AK, Zeymer U, et al. Chronic total coronary occlusions in patients with stable angina pectoris: impact on therapy and outcome in present day clinical practice. Clin Res Cardiol 2009;98:435–41.
Jeroudi OM, Alomar ME, Michael TT, et al. Prevalence and management of coronary chronic total occlusions in a tertiary Veterans Affairs hospital. Catheter Cardiovasc Interv 2014;84: 637–43.
Brilakis ES, Banerjee S, Karmpaliotis D, et al. Procedural outcomes of chronic total occlusion percutaneous coronary intervention: a report from the NCDR (National Cardiovascular Data Registry). J Am Coll Cardiol Cardiovasc Interv 2015;8:245–53.
Joyal D, Afilalo J, Rinfret S. Effectiveness of recanalization of chronic total occlusions: a systematic review and meta-analysis. Am Heart J 2010;160:179–87.
George S, Cockburn J, Clayton TC, et al. Long-term follow-up of elective chronic total coronary occlusion angioplasty: Analysis from the U.K. Central Cardiac Audit Database. J Am Coll Cardiol 2014;64:235–43
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