Percutaneous coronary intervention (PCI) procedures for patients with chronic total occlusions (CTOs) are performed infrequently, according to a study published Feb. 17 in JACC: Cardiovascular Interventions. The study also found that operators with more experience performing this procedure had greater success than inexperienced ones. The health of the patients also played a role in the outcomes. 

Using data from the ACC's CathPCI Registry, researchers looked at 594,510 PCI procedures between July 1, 2009, through March 31, 2013, to determine how often CTO PCI procedures were performed, what the success rates were, and how often major adverse cardiac events occurred. Researchers found that during the study period, CTO PCI represented only 3.8 percent (22,365 procedures) of the total number of PCI procedures performed  for stable coronary artery disease, although its frequency has been increasing slightly over time (3.2 percent of PCIs in 2009 vs. 4.8 percent in 2013).  

When compared with outcomes for patients with non-CTO PCI, those for patients with chronic total occlusions were less successful (59 percent vs. 96 percent), but there was marked variability across centers. The researchers also found a higher risk for complications before, during, or after the procedure among patients in the CTO PCI group compared to those in the non-CTO PCI group (1.6 percent vs. 0.8 percent).

Importantly, the study found a correlation between procedural success and experience of the operators. The success rate was 53 percent for operators who performed fewer than five a year; 62 percent for those who performed five-to-ten procedures; and 75 percent for those who performed more than ten procedures. 

The health of the patients also contributed to the success of the CTO PCI. The findings suggest that those patients with successful outcomes were younger than those with failed outcomes and had lower rates of prior myocardial infarction, diabetes, prior stroke or prior coronary artery bypass graft surgery. 

“We demonstrated that CTO PCI [may be] underutilized and highlighted how important it is for these procedures to be performed by experienced centers and operators, who are committed to mastering the techniques required to safely achieve high success rates in these complex lesions,” noted the study's lead author, Emmanouil S. Brilakis, MD, PhD, FACC, director of the cardiac catheterization laboratories at VA North Texas Healthcare System and an associate professor of medicine at University of Texas Southwestern Medical School.

In an accompanying editorial, John A. Bittl, MD, FACC, an interventional cardiologist at Munroe Regional Medical Center in Ocala, FL,  wrote that "The current study adds to the emerging data to suggest that successful CTO PCI improves survival... and puts [these findings] into clearer perspective by first clarifying that successful CTO PCI resulted in lower in-hospital mortality rates than did failed CTO PCI (0.0 percent vs. 1.1 percent). Additional observations suggest that the mortality differences after discharge were caused in part by confounding... Patients with successful procedures were healthier at baseline than the patients who then 'took a hit' from a failed CTO PCI."   

Bittl also commented that "the authors of the current study have made a critical observation... A larger annual volume of CTO PCI procedures per operator was associated with superior outcomes." He concludes that "the skills required for successful CTO PCI are teachable. Familiarity with advanced techniques leads to improved outcomes."

        

Keywords: Cardiac Catheterization, Coronary Artery Bypass, Coronary Artery Disease, Coronary Disease, Diabetes Mellitus, Hospital Mortality, Myocardial Infarction, Percutaneous Coronary Intervention, Registries, Research Personnel, Stroke

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