Abstract
Coronary artery chronic total occlusions (CTO) are frequently encountered during coronary angiography; however percutaneous recanalization has historically been technically challenging and an important determinant for referral to coronary artery bypass surgery or for medical therapy alone. Recent advances in interventional equipment and innovative approaches to crossing CTO have significantly increased the success rate of percutaneous treatment. Although there is only one relevant randomized control trial (RCT) performed to date, several large, nonrandomized studies have consistently reported improvement in clinical outcomes, including improved survival and relief of angina, when successful percutaneous treatment of CTO was compared with unsuccessful revascularization. These positive observational results have encouraged the initiation of several RCTs which will provide more robust evidence on clinical outcomes of CTO-PCI compared with guideline-directed medical therapy (GDMT) alone.
Highlights
Percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) has been rapidly evolving in recent years
In patients with multivessel coronary artery disease (CAD) who were screened for the Bypass Angioplasty Revascularization Investigation (BARI) trial comparing balloon angioplasty to coronary artery bypass graft (CABG), the presence of a CTO was the most common angiographic characteristic which influenced the decision against enrollment (Bourassa et al, 1995)
There is a high prevalence of CTO in the CAD population, and historically CTOs have been undertreated with regards to percutaneous revascularization
Summary
Percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) has been rapidly evolving in recent years. An attempt at PCI is performed at a rate of only 10% to 15% of all patients with CTO (Fefer et al, 2012; Cohen et al, 2003; Grantham et al, 2009). In patients with multivessel CAD who were screened for the Bypass Angioplasty Revascularization Investigation (BARI) trial comparing balloon angioplasty to CABG, the presence of a CTO was the most common angiographic characteristic which influenced the decision against enrollment (Bourassa et al, 1995). In the Canadian registry reflecting the time period from 2008 to 2009 (Fefer et al, 2012), the majority of CTO lesions in the CAD group without prior CABG were left un-revascularized and managed with medical therapy alone (64% of cases). Patients with CTO (compared to CAD patients without CTO) were still more likely to be referred for revascularization with CABG, probably due to a strong association of CTO with multivessel CAD (55% with 3-vessel CAD in the CTO group, versus 20% in non-CTO group)
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