Abstract
Limited data are available on clinical outcome of patients with previously failed or not attempted chronic total occlusion (CTO) recanalization by percutaneous coronary intervention (PCI). The aim of the study is to determine prevalence and predictors of cardiac death in patients with CTO not revascularized by PCI. Double-center study analyzing data of 1.345 consecutive patients with at least one CTO between 1998 and 2008. Of these, 847 patients were successfully revascularized (Revascularized group) and 498 patients were not revascularized (Not revascularized group) either due to failure of CTO-PCI (n=337) or because no attempt was made (n=161). At 4-year clinical follow-up, Not revascularized patients had a significantly higher rate of cardiac mortality (8.5% vs. 2.5%, p<0.0001) and sudden cardiac death (2.7% vs. 0.5%, p=0.001) compared to those Revascularized. The separate adjusted Cox-model analysis made for Not revascularized patients showed the most significant independent predictors of cardiac death were: chronic renal failure [HR (CI), 6.0 (2.66-13.80)], low-LVEF [5.7 (2.84-11.58)], insulin-dependent diabetes mellitus (IDDM) 4.6 [(1.96-10.97)]. In the Revascularized group, the presence of 3-vessel disease was the only significant independent predictor of cardiac death [4.4 (1.40-13.70)]. CTO patients Not revascularized had a significant higher rate of cardiac mortality and sudden cardiac death compared to those Revascularized. Within Not revascularized patients, the presence of low-LVEF, or CRF or IDDM was associated with an incidence of cardiac death at least 4 times higher than those without the same risk factors.
Highlights
In 15% - 30% of all coronary angiograms performed in patients with single or multivessel coronary artery disease, at least one coronary chronic total occlusion (CTO) is present [1,2,3]
40% of these patients are treated medically or a large portion of these patients is referred for coronary artery bypass grafting (CABG) surgery, especially those with multivessel disease and a high syntax-score [3]
A simple step-up approach with the new generation of wires and microcatheters might result in reduced failure rates in easy CTO lesions and those with intermediate difficulty
Summary
In 15% - 30% of all coronary angiograms performed in patients with single or multivessel coronary artery disease, at least one coronary chronic total occlusion (CTO) is present [1,2,3]. 40% of these patients are treated medically or a large portion of these patients is referred for coronary artery bypass grafting (CABG) surgery, especially those with multivessel disease and a high syntax-score [3] This reluctance to perform percutaneous coronary intervention (PCI) has historically been driven mainly by anatomical factors, related to the CTO. A large range of CTO-dedicated GWs and devices have been developed to reduce treatment failure rates Such an abundant choice of GW types, all with specific characteristics (polymer-coated vs non-coated; jacket vs sleeve coatings; spring vs non-spring coil; low vs high tip load; ...) confuses the operator, being unable to build up sufficient experience with one type or set of wires, especially in low or intermediate PCI volume centers. A simple step-up approach with the new generation of wires and microcatheters might result in reduced failure rates in easy CTO lesions and those with intermediate difficulty
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