Percutaneous Coronary Intervention Versus Optimal Medical Therapy for Chronic Total Coronary Occlusion With Well-Developed Collaterals

Abstract

Background: The impact of percutaneous coronary intervention (PCI) on chronic total occlusion in patients with well-developed collaterals is not clear.

Methods and results: A total of 640 chronic total occlusion patients with collateral flow grade ≥2 were divided into 2 groups; chronic total occlusion patients either treated with PCI (the PCI group; n=305) or optimal medical therapy (the optimal medical therapy group; n=335). To adjust for potential confounders, a propensity score matching analysis was performed. Major clinical outcomes were compared between the 2 groups up to 5 years. In the entire population, the PCI group had a lower hazard of myocardial infarction (hazard ratio [HR], 0.177; P=0.039; 95% confidence interval [CI], 0.03-0.91) and the composite of total death or myocardial infarction (HR, 0.298; P=0.017; 95% CI, 0.11-0.80); however, it showed higher hazard of target lesion revascularization (HR, 3.942; P=0.003; 95% CI, 1.58-9.81) and target vessel revascularization (HR, 4.218; P=0.001; 95% CI, 1.85-9.60). After propensity score matching, a total of 158 matched pairs were generated. Although the PCI group showed a higher hazard of target lesion revascularization (HR, 2.868; P=0.027; 95% CI, 1.13-7.31) and target vessel revascularization (HR=2.62; P=0.022; 95% CI, 1.15-5.97), it still exhibited a lower incidence of the composite of total death or myocardial infarction (HR, 0.263; P=0.017; 95% CI, 0.087-0.790). The mean ejection fraction was improved from 47.8% to 51.6% (P<0.001) after PCI.

Conclusions: In our study, successful revascularization by PCI for chronic total occlusion lesions with well-developed collaterals was associated with lower incidence of death and myocardial infarction, improved left ventricular function, but increased repeat revascularization rate.

Keywords: chronic total occlusion; collateral circulation; medical therapy; percutaneous coronary intervention.

Figure 1

Study flow chart. CTO indicates chronic total occlusion; OMT, optimal medical therapy; PCI, percutaneous coronary intervention.

Figure 2

Annual trends in success rate of CTO PCI. CTO indicates chronic total occlusion; PCI, percutaneous coronary intervention.

Figure 3

The composite total death and myocardial infarction free survival by Kaplan–Meier curves. CI indicates confidence interval; HR, hazard ratio; OMT, optimal medical therapy; PCI, percutaneous coronary intervention.

Figure 4

Changes of LVEF using paired t test analysis in the first 1.7 years after revascularization. A through C, Change of LVEF in CTO‐PCI patients after propensity score matching; all CTO‐PCI patients (A), CTO‐PCI patients with reduced LVEF (≤50%, B), and CTO‐PCI patients with near‐normal LVEF (>50%, C). D through F, Change of LVEF in CTO‐OMT patients after propensity score matching; All CTO‐OMT patients (D), CTO‐OMT patients with reduced LVEF (≤50%, E), and CTO‐OMT patients with near‐normal LVEF (>50%, F). G, Comparison for changed LVEF between CTO‐OMT with CTO‐PCI patients using Student t test. CTO indicates chronic total occlusion; LVEF, left ventricular ejection fraction; OMT, optimal medical therapy; PCI, percutaneous coronary intervention.

Figure 5

Subgroup analysis of the composite of total death and myocardial infarction. CCS indicates Canadian Cardiovascular Society class; CI, confidence interval; CTO, chronic total occlusion; LAD, left anterior descending artery; LV, left ventricular; OMT, optimal medical therapy; PCI, percutaneous coronary intervention.