The evidence base for revascularisation of chronic total occlusions

Abstract

When patients with ischaemic heart disease are considered for revascularisation the Heart Team's aim is to choose a therapy that will provide complete relief of angina for an acceptable procedural risk. Complete functional revascularisation of ischaemic myocardium is thus the goal and for this reason the presence of a chronic total occlusion (CTO) - which remain the most technically challenging lesions to revascularise percutaneously - is the most common reason for selecting coronary artery bypass surgery. From the behaviour of Heart Teams it is clear that physicians believe that CTOs are important. Yet when faced with patients with CTOs for whom surgery appears excessive (e.g. nonproximal LAD) or too high risk, there remains a reluctance to undertake CTO PCI, despite significant recent advances in procedural success and safety and a considerable body of evidence supporting a survival benefit following successful CTO PCI. This article reviews the relationship between CTOs, symptoms of angina, ischaemia and left ventricular dysfunction and further explores the evidence relating their treatment to improved quality of life and prognosis in patients with these features.

Fig. (1)

Temporal trends in cumulative angiographic success rates and major procedural complication rates, presenting according to the study publication year. Adapted from Patel VG, Brayton KM, Tamayo A, et al. Angiographic Success and Procedural Complications in Patients Undergoing Percutaneous Coronary Chronic Total Occlusion Interventions: A Weighted Meta-Analysis of 18,061 Patients From 65 Studies. JACC Cardiovasc Interv 2013; 6(2): 128-36.

Fig. (2)

PubMed publications in the field of coronary chronic total occlusions over the last 10 years

Fig. (3)

Effect of successful versus failed CTO recanalization on all-cause mortality during available follow-up. Adapted from Joyal D, Afilalo J, Rinfret S. Effectiveness of recanalization of chronic total occlusions: a systematic review and meta-analysis. Am Heart J 2010; 160(1): 179-87.

Fig. (4)

Kaplan–Meier analysis of cardiac death incidence in Revascularized (R) and Not revascularized (NR) CTO patients stratified by the presence (+) or absence (-) of low Left Ventricular Ejection Fraction (LVEF, panel A), chronic renal failure (CRF, panel B), Insulin-Dependent Diabetes Mellitus (IDDM, panel C) and coronary 3-vessel disease (3Vessels, panel D). Adapted from Godino C, Bassanelli G, Economou FI, et al. Predictors of cardiac death in patients with coronary chronic total occlusion not revascularized by PCI. Int J Cardiol 2013.