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PCI for Chronic Total Occlusion: The Michigan Experience
Quick Takes
- The success rate of CTO-PCI in contemporary practice remains far below the >80% reported by high-volume experience centers.
- The risk versus benefits of CTO-PCI should be weighed properly, specifically in those with lower angina class, as the major impact of CTO-PCI remains on improving angina symptoms.
- Clinicians should consider a functional study to determine if a coronary artery with CTO is a culprit in a symptomatic patient who failed optimal medical therapy, and to determine the severity/extent of ischemia in the coronary territory it supplies prior to PCI.
Study Questions:
What is the performance and what are the outcomes of chronic total occlusion (CTO)–percutaneous coronary intervention (PCI) in Michigan?
Methods:
The investigators evaluated patients enrolled in the BMC2 (Blue Cross Blue Shield of Michigan Cardiovascular Consortium) registry (2010-2017) to study uptake and outcomes of CTO-PCI in Michigan. CTO-PCI was defined as intervention of 100% occluded coronary artery ≥3 months old. Logistic regression models were used to evaluate differences in outcomes between CTO-PCI cases and non–CTO-PCI cases, adjusting for baseline clinical and demographic factors.
Results:
Among 210,172 patients enrolled in the registry, 7,389 (3.5%) CTO-PCIs were attempted with 4,614 (58.3%) achieving post-procedural TIMI (Thrombolysis In Myocardial Infarction) 3 flow. The proportion of PCIs performed on CTO increased over the study period (2.67% in 2010 to 4.48% in 2017); 30 of 47 hospitals performed >50 CTOs in 2017. Preprocedural angina class <2 was present in one-quarter and functional assessment for ischemia was performed in 46.6% of patients. Major complications occurred in 245 patients (3.3%) and included death (1.4%), postprocedural stroke (0.4%), cardiac tamponade (0.5%), and urgent coronary artery bypass grafting (1.3%). Procedural success improved modestly from 44.5% in 2010 to 54.9% in 2017 (p for trend < 0.001). In-hospital mortality and major adverse cardiac events (MACE) for CTO-PCI remained unchanged over the study period (p for trend = 0.247 and 0.859).
Conclusions:
The authors concluded that rates of CTO-PCI in Michigan have increased over the study period, and while the success rate of CTO-PCI has increased modestly in contemporary practice, it remained far below the >80% reported by select high-volume CTO operators.
Perspective:
This registry study reports that CTO-PCI constituted only a minority of all PCIs performed in Michigan, but rates had increased over time. Furthermore, while the success rate of CTO-PCI has increased modestly in contemporary real-world practice, it remained far below the >80% reported by high-volume experience centers. Of importance, periprocedural MACE or death has remained steady over time. Given these findings, there is need for appropriate patient selection, particularly with regard to symptoms and functional assessment of CTO lesions before subjecting patients to the increased procedural risk associated with CTO-PCI.
Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Pericardial Disease, Prevention, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and SIHD
Keywords: Angina Pectoris, Cardiac Tamponade, Coronary Artery Bypass, Coronary Occlusion, Hospital Mortality, Myocardial Ischemia, Outcome Assessment, Health Care, Percutaneous Coronary Intervention, Secondary Prevention, Stroke
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