CTO PCI

Successful CTO PCI Associated with Increased Survival

August 21, 2017

Key Takeaways

  • Criticism of successful CTO PCI exists, particularly in regard to its effect on mortality.
  • In this large contemporary cohort of patients with CTOs, successful CTO PCI correlated with a lower mortality risk as well as a decreased CABG requirement.

Reference: Tsai TT et al. JACC Cardiovasc Interv. 2017;10(9):866-875.

According to the American College of Cardiology/American Heart Association’s guidelines for coronary intervention, a percutaneous coronary intervention (PCI) of a chronic total occlusion (CTO) is considered appropriate when the procedure is performed by an experienced, expert operator.1

The use rate of PCI for CTOs is low, with only 3.8% of total PCIs directed toward CTO management.1 High complication rates, increased procedural complexity, and lack of clear, established long-term benefits of the procedure contribute to a low number of CTO PCI procedures. Successful CTO PCI interventions, despite their inherent risks, are associated with significant symptoms relief, improvement in left ventricular ejection fraction, and higher survival.3,4,5

Research by Tsai et al evaluated follow-up data from a large cohort of coronary angiography patients and examined the incidence of CTOs and the success rates of CTO PCI.6 Additional endpoints, such as post-procedural complications and long-term survival, were also analyzed. Patients with obstructive coronary artery disease (CAD), which was defined as ≥50% stenosis in the left main coronary artery or ≥70% stenosis in any other coronary artery, were included. In total, examination of 2394 elective CTO PCIs were included in the final analysis. Successful CTO PCIs were observed in the majority of patients (79.7%).

Most treated CTOs were in the right coronary artery distribution (42.4%) and left anterior descending (LAD) coronary artery (23.5%). CTOs treated successfully were usually in the left anterior descending coronary artery and tended to feature shorter length. The technical success rate of treated CTOs was 79.8%. Complications occurring during the procedure often occurred in patients with unsuccessfully treated lesions.

Following a multivariate analysis, researchers determined that patient comorbidities did not influence the success rate of CTO PCI. Adjustment for baseline characteristics found that successful CTO PCI was an independent predictor of 2-year of survival. These findings mirror those from the Mid-America Heart Institute’s registry which showed a 10-year survival benefit of successful CTO PCI compared with failed CTO PCI (73.5% vs 65.1%; p = 0.001).7 Authors concluded that CTO PCI failure may be an indicator for unmeasured patient disease burden.

In an accompanying editorial, Dr. Aaron Grantham explains that the size of the study population was one of the greatest strengths of this study.8 He adds,

“This is particularly important with regard to their descriptive analysis of CTO PCI utilization in the VA system, where outcomes may be different than the general population due to the unique makeup of the population.”

In this patient population, elective and successful CTO PCI was associated with a high rate of successful revascularization, decreased need for CABG, and increased survival. To realize the full benefits and risks of successful CTO PCI, randomized controlled trials are necessary.
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References:

  1. Levine GN, Bates ER, Blankenship JC, et al. 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol. 2011;58:e44–122.
  2. 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 Intv. 2015;8(2):245–253.
  3. Olivari Z, Rubartelli P, Piscione F, et al. Immediate results and one-year clinical outcome after percutaneous coronary interventions in chronic total occlusions: data from a multicenter, prospective, observational study (TOAST-GISE). J Am Coll Cardiol. 2003;41(10):1672-1678.
  4. Melchior JP, Doriot PA, Chatelain P, et al. Improvement of left ventricular contraction and relaxation synchronism after recanalization of chronic total coronary occlusion by angioplasty. J Am Coll Cardiol. 1987;9(4):763-768.
  5. Sirnes PA, Myreng Y, Mølstad P, Bonarjee V, Golf S. Improvement in left ventricular ejection fraction and wall motion after successful recanalization of chronic coronary occlusions. Eur Heart J. 1998;19(2):273-281.
  6. Tsai TT, Stanislawski MA, Shunk KA, et al. Contemporary Incidence, Management, and Long-Term Outcomes of Percutaneous Coronary Interventions for Chronic Coronary Artery Total Occlusions: Insights From the VA CART Program. JACC Cardiovasc Interv. 2017;10(9):866-875.
  7. Suero JA, Marso SP, Jones PG, et al. Procedural outcomes and long-term survival among patients undergoing percutaneous coronary intervention of a chronic total occlusion in native coronary arteries: a 20-year experience. J Am Coll Cardiol. 2001;38(2):409-414.
  8. Grantham JA. Survival and Chronic Total Occlusion Percutaneous Coronary Intervention: The Never-Ending Debate Continues. JACC: Cardiovascular Interventions. 2017;10(9):876-878.

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