Abstract
Coronary chronic total occlusions (CTOs) represent the most technically challenging lesion subset that interventional cardiologists face. CTOs are identified in up to one third of patients referred for coronary angiography and remain seriously undertreated with percutaneous techniques. The complexity of these procedures and the suboptimal success rates over a long period of time, along with the perception that CTOs are lesions with limited scope for recanalization, account for the underutilization of CTO Percutaneous Coronary Intervention (PCI). During the last years, dedicated groups of experts in Japan, Europe and United States fostered the development and standardization of modern CTO recanalization techniques, achieving success rates far beyond 90 %, while coping with lesions of increasing complexity. Numerous studies support the rationale of CTO revascularization following documentation of viability and ischemia in the territory distal to the CTO. Successful CTO PCI provide better tolerance in case of future acute coronary syndromes and can significantly improve angina and left ventricular function. Randomized trials are on the way to further explore the prognostic benefit of CTO revascularization. The following review reports on the theory and the most recent advances in the field of CTO recanalization, in an attempt to promote a more balanced approach in patients with chronically occluded coronary arteries.
Highlights
Coronary Chronic Total Occlusions (CTOs) are identified in up to one third of patients with coronary artery disease referred for coronary angiography [1,2,3], with an incidence increasing with age [4]
Successful CTO recanalization is related to improved survival, improvement in anginal status and left ventricular function, increased exercise tolerance, decreased need for Coronary Artery Bypass Grafting (CABG) and better tolerance of future acute coronary syndromes [5,6,7,8,9]
Indications to surgery or angioplasty are based on the same criteria and the decision between one or the other is purely technical; surgical revascularization may be favored in the presence of left main coronary artery disease, complex triple vessel disease, occluded proximal left anterior descending artery and multiple CTOs with a relatively low anticipated success rate [59]
Summary
Coronary Chronic Total Occlusions (CTOs) are identified in up to one third of patients with coronary artery disease referred for coronary angiography [1,2,3], with an incidence increasing with age [4]. The success rates of operators experienced in conventional CTO PCI techniques was never greater than 60– 70 % [6], considerably lower than the success rates in non-occlusive coronary artery disease.
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