Future Directions of Chronic Total Occlusion Management: Identifying the Right Patient for Intervention With a Focus on Biomarkers

The management of a chronic total occlusion (CTO) of a coronary artery has been a conundrum in interventional cardiology, as revascularization has not been proven to provide a mortality benefit. However, there are subgroups of patients with a CTO that have high levels of ischemia on myocardial perfusion imaging and high circulating levels of high sensitivity troponin-I (hsTn-I) and N terminal pro-brain natriuretic peptide (NT pro-BNP) that are at a particularly high-risk for adverse cardiovascular events. These high-risk subgroups of patients with a CTO may have not been well represented in prior clinical trials, and may gain a mortality benefit from revascularization of the CTO. Conversely, patients with low levels of ischemia and these biomarkers are at lower risk and may not gain a mortality benefit from revascularization of their CTO. It is important for future randomized controlled trials to investigate the efficacy of CTO PCI in patients with elevated biomarkers and high ischemic burden on myocardial perfusion imaging to determine if patients at high-risk gain a mortality benefit from revascularization.

Myocardial Infarction and All-Cause Mortality Following Percutaneous Coronary Intervention Versus Conservative Treatment of Chronic Total Occlusions: A West Denmark Heart Registry Study

BACKGROUND

Chronic coronary total occlusions (CTO) represent a therapeutic challenge, and results of randomized clinical trials and observational studies comparing conservative treatment versus percutaneous coronary intervention (PCI) are underpowered.

AIMS

To assess myocardial infarction (MI) and all-cause mortality in consecutive patients with CTO lesions.

METHODS

Using data from the West Denmark Heart Registry, patients with chronic coronary syndrome and a 100% occluded vessel by invasive coronary angiography (ICA) were identified. Patients were stratified according to PCI within 90 days. Five-year risk of MI and all-cause mortality was calculated using cause-specific Cox-models and g-formula methods. Subsequently, models were stratified on sex, diabetes, estimated glomerular filtration rate above 60 mL/min, procedure before 2012, and history of cardiac surgery. The risk was calculated for patients who did not experience MI or death within 30 days of the initial ICA.

RESULTS

A total of 7675 patients were included in the study, of whom 3129 patients underwent PCI, and 4546 patients were treated conservatively. PCI- and conservatively treated patients had comparable risks of MI (13.1% [95% confidence interval [CI] 12.0%-14.3%] for patients who underwent PCI vs. 13.4% [95% CI 12.4%-13.4%] for patients who received conservative treatment). For all-cause mortality, results were 14.4% (95% CI 13.3%-15.5%) versus 18.9% (95% CI 17.8%-20.0%), respectively. Results were consistent across subgroups. However, CTO-PCI-treated patients with previous heart surgery were at higher risk of MI.

CONCLUSIONS

Patients who underwent CTO-PCI had a comparable 5-year risk of MI and lower all-cause mortality as compared to conservatively treated patients.

Prospective Evaluation of Treatment Strategies in Patients Presenting With Chronic Total Occlusion: The PETS-CTO Registry

BACKGROUND

The management of patients with chronic total occlusion (CTO) poses a persistent challenge, necessitating a tailored treatment strategy.

AIMS

This study aimed to investigate the intricate interplay between treatment selection, ischemia burden reduction, and symptom relief in patients with isolated CTO lesions.

METHODS

The Prospective Evaluation of Treatment Strategies in patients presenting with Chronic Total Occlusion (PETS-CTO) registry is a prospective, non-randomized study that evaluated patients at enrollment and follow-up using the Seattle Angina questionnaire (SAQ) and stress ischemia tests. Patients were allocated into three treatment arms: optimal medical therapy (OMT), percutaneous coronary intervention (C TO-PCI), or coronary artery bypass grafting (CABG). Changes in the angina symptoms and ischemic burden were the primary endpoints, while a clinical composite of death, myocardial infarction, and angina-related rehospitalization was considered as the secondary outcome.

RESULTS

Among 157 patients, 45% were in the CTO-PCI group, 45% in the OMT group, and 10% underwent CABG. CTO-PCI group demonstrated favorable changes in summary SAQ score (12.3%, 95% CI: 3.4%-21.5%, p = 0.008) compared to OMT. CTO-PCI patients more frequently shifted from an ischemic to a nonischemic stress test at follow-up compared to OMT (60% vs. 5.6%, p < 0.001). No correlation was observed between angina scores and proven ischemia at baseline and follow-up assessments.

CONCLUSIONS

Effective management of CTO requires comprehensive evaluation, and although angina relief and ischemic burden are individually influential, our findings reveal a lack of correlation between these factors, emphasizing the complexity in guiding treatment decisions (PETS-CTO; NCT04145167).

Myocardial perfusion imaging in advanced coronary artery disease

Myocardial perfusion imaging (MPI) is widely adapted as a noninvasive technique to assess the presence and extent of ischemia in patients with symptoms suggestive of obstructive coronary artery disease (CAD). However, as CAD advances, several factors can complicate the interpretation of MPI, subsequently impacting clinical decision-making. This review focuses on the utility of MPI by means of cardiac magnetic resonance (CMR) imaging, single-photon emission computed tomography (SPECT) and positron emission tomography (PET) in patients with advanced CAD-the latter characterized by documented CAD (i.e. prior myocardial infarction [MI] and/or percutaneous coronary intervention [PCI]), prior coronary artery bypass grafting (CABG) or the presence of a chronic total occlusion (CTO). It will discuss factors impacting the interpretation of MPI, the diagnostic performance for detecting obstructive CAD and coronary microvascular dysfunction (CMD), as well as the role of MPI in guiding revascularization.

Prevalence and Clinical Parameters Associated With Chronic Total Occlusions in Patients With Chronic Coronary Syndromes: Insights From a Nationwide Registry

Background and Aims

The prevalence of coronary chronic total occlusions (CTO) among patients with chronic coronary syndrome (CCS) and their associations with clinical factors have received limited study. We analyzed a national database registry to determine the prevalence, location, and parameters associated with coronary CTOs.

Methods

We identified all CCS patients without prior coronary artery bypass graft surgery (CABG) who underwent coronary angiography in the Persian CardioVascular Disease Registry (PCVDR). We compared the baseline demographics and characteristics of patients with vs. without at least one CTO lesion. We used logistic regression analysis to identify parameters associated with coronary CTOs.

Results

Among the 40,161 patients with CCS who underwent coronary angiography between March 2019 and December 2023, 6805 (17.86%) had at least one CTO. CTO patients were significantly older (64.43 ± 8.96 years vs. 62.64 ± 9.54 years, p < 0.001) and more likely to be men (75.3% vs. 54.4%, p < 0.001). The left anterior descending artery (70.4%) and right coronary artery (16.5%) were the most common CTO lesion locations. Older age (adjusted odds ratio [aOR] 95% confidence intervals [CI] 1.024 (1.021-1.028), male gender (aOR 2.865 (2.685-3.058), any smoking (aOR 1.256 (1.145-1.378), diabetes mellitus (aOR 1.372 (1.288-1.460), and dyslipidemia (aOR 1.166 (1.096-1.239) were independently associated with the presence of a CTO.

Conclusion

Approximately 1 in 5 CCS patients without prior CABG undergoing coronary angiography in this national database registry had a CTO. Advanced age, male gender, history of smoking, diabetes mellitus, and dyslipidemia were associated with higher likelihood of coronary CTOs.

Recent Advances in Coronary Chronic Total Occlusions

Coronary chronic total occlusions (CTOs) have been a point of interest of the medical community for the last decade. The natural history of CTOs was for a long time unknown, as the presence of a single CTO was the most frequent cause for the exclusion of patients from randomized controlled trials (RCTs). Recent CTO RCTs have failed to show any benefit in terms of hard endpoints as major adverse cardiovascular events, but have shown a significant improvement in quality of life, as well in the frequency of angina; however, these studies are characterized by the limitation of the short duration of their follow-up period. Real-world data from observational studies indicate a significant improvement in cardiovascular death and overall mortality, suggesting that the results depend on the duration of the follow-up, and not on the procedure per se. The aim of the current review is to summarize all the existing RCTs, and to analyze the most important registries, as well as to present the current development of techniques to boost the successful interventional treatment of CTOs.

Assessment of chronical total occlusions management in France: The ENCOCHE Registry, a prospective, multicentric study

BACKGROUND

Coronary chronic total occlusions (CTO) are frequent, and coronary angioplasty has been increasingly used in recent years for lesion revascularisation. However, to date, no dedicated multicentric prospective study is available in France.

AIM

To describe the characteristics of CTO patients and to assess current treatment strategies in French catheterisation laboratory practice.

METHODS

Patients presenting with CTOs were included from 16/09/2021 to 13/12/2021 over two consecutive prospective phases. In phase I (one month), data were collected to include all patients presenting CTO at diagnostic angiography. In phase II (two months), data were collected focusing on patients who underwent CTO-PCI.

RESULTS

A total of 1303 patients (1460 CTOs) were included in 68 French centres. The mean age was 67.7±10.7 years and 84.3% of the patients were men. The prevalence of prior PCI (44.6%), and diabetes mellitus (35.6%) was high. In phase I, multivessel coronary artery disease was detected in two-thirds of cases, and most of them (88.5%) had a single CTO. The mean J-CTO score was 1.9±1.2, with a proportion of difficult and very difficult CTO (J CTO score ≥2) of 61.1%. The selected treatment was medical therapy in 57% of cases, coronary angioplasty in 30% and bypass surgery in 13%. In phase II, 528 patients were included with a mean J-CTO score of 1.8±1.2. Successful guidewire crossing through CTO lesion was obtained with an antegrade access in 89% of patients. Procedural success rate of CTO-PCI was 80%, with a rate of major in-hospital complications of 1% (death: 0.4%, MI: 0.2%, stroke: 0.2%, emergency CABG: 0.2%).

CONCLUSION

This prospective study provides a snapshot of CTOs prevalence and CTO treatment strategies in France in 2021.

Short- and long-term outcomes of antegrade versus retrograde approaches in patients undergoing percutaneous coronary intervention for chronic total occlusion: A meta-analysis

BACKGROUND

Chronic Total Occlusion (CTO) involves severe coronary artery blockage that impairs blood flow and affects 15-20 % of patients undergoing coronary angiography and over 40 % with diabetes or heart failure. Percutaneous Coronary Intervention (PCI) is used to restore blood flow in such cases. The retrograde approach, developed due to lower success with the antegrade method in complex cases, improves outcomes but increases complications. This meta-analysis compares the efficacy and safety of both approaches to guide clinical practice.

METHODS

A comprehensive literature search was conducted on PubMed, Embase, Google Scholar, and Scopus until June 5, 2024, to find studies comparing antegrade and retrograde approaches in CTO-PCI patients. Pooled risk ratios (RR) with 95 % confidence intervals (CI) were calculated using R software (version 4.4.1), with significance set at p < 0.05. Random-effects models were used for all analyses.

RESULTS

Our analysis included 22 observational studies with 49,152 CTO-PCI patients: 35,844 in the antegrade arm and 13,308 in the retrograde arm. The antegrade approach showed significantly lower risks of in-hospital outcomes, including mortality [RR: 0.45; p < 0.001], myocardial infarction [RR: 0.37; p < 0.001], major adverse cardiovascular events [RR: 0.34; p < 0.001], and cerebrovascular events [RR: 0.50; p = 0.011]. Long-term outcomes, such as all-cause mortality [RR: 0.71; p = 0.157] and myocardial infarction [RR: 0.76; p = 0.438], were comparable between both approaches.

CONCLUSION

The antegrade technique shows better outcomes and procedural advantages over retrograde revascularization, though long-term outcomes are similar. Further studies, especially randomized controlled trials are needed to confirm these findings.

Impact of a Chronic Total Occlusion on Outcomes After FFR-Guided PCI or Coronary Bypass Surgery: A FAME 3 Substudy

BACKGROUND

The clinical impact of a chronic total occlusion (CTO) in patients with 3-vessel coronary artery disease undergoing fractional flow reserve-guided percutaneous coronary intervention (PCI) with current-generation drug-eluting stents or coronary artery bypass grafting (CABG) is unclear.

METHODS

The FAME 3 trial (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation 3) compared fractional flow reserve-guided PCI with CABG in patients with 3-vessel coronary artery disease. The primary end point was major adverse cardiac and cerebrovascular events, a composite of death, myocardial infarction, stroke, or repeat revascularization at 1 year. In this substudy, the 3-year outcomes were analyzed in patients with or without a CTO.

RESULTS

Of the patients randomized to PCI or CABG in the FAME 3 trial, 305 (21%) had a CTO. In the PCI arm, revascularization of the CTO was attempted in 61% with a procedural success rate of 88%. The incidence of major adverse cardiac and cerebrovascular events at 3 years was not significantly different between those with or without a CTO in both the PCI (15.2% versus 20.1%; adjusted hazard ratio, 0.62 [95% CI, 0.38-1.03]; P=0.07) and the CABG (13.0% versus 12.9%; adjusted hazard ratio, 0.96 [95% CI, 0.55-1.66]; P=0.88) arms. In those without a CTO, PCI was associated with a significantly higher risk of major adverse cardiac and cerebrovascular events compared with CABG (adjusted hazard ratio, 1.61 [95% CI, 1.20-2.17]; P<0.01) but not in those with a CTO (adjusted hazard ratio, 1.21 [95% CI, 0.64-2.28]; P=0.56; Pinteraction=0.31).

CONCLUSIONS

The presence of a CTO did not significantly impact the treatment effect of PCI versus CABG at 3 years in patients with 3-vessel coronary artery disease.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02100722.

The impacts of percutaneous coronary intervention to treat chronic total occlusion of right coronary artery on the 5-year prognosis: A single-centered retrospective study

BACKGROUND

Chronic total occlusions (CTO) occur in about 20% of patients referred for coronary angiography, and right coronary artery (RCA) CTO has been reported in 38-50% of the entire CTO population. Limited data on angiographic and procedural characteristics of RCA-CTO and the risk of adverse cardiac events asks for a detailed study.

METHODS

From 2010 to 2013, patients with attempted revascularization of at least one CTO lesion were included and followed up to 5 years after PCI. Eligible patients are assigned to RCA-CTO and non-RCA-CTO groups based on their target vessels. The primary endpoint was major adverse cardiovascular events (MACEs; a composite of all-cause death, myocardial infarction (MI) or rehospitalization for heart failure), and secondary endpoints were cardiac death, target lesion revascularization (TLR) and target vessel revascularization (TVR).

RESULTS

The present study included 2659 eligible patients, among which 1285 patients were assigned to the RCA-CTO group, whereas 1374 patients were assigned to the non-RCA-CTO group. Lesions in RCA had longer lesion length, higher J-CTO score, higher rates of severe vessel tortuosity, a higher percentage of Rentrop grade 2-3, and more likely to be re-try lesion than those in LAD or LCX (all P < 0.01). CTO lesions in RCA reached less successful recanalization and post-procedural TIMI 3 flow (all <0.01). Multivariate Cox analysis revealed that RCA-CTO was not associated with primary outcome MACEs. Besides MACEs, RCA-CTO was also not associated with cardiac death, but was significantly associated with TLR and TVR (adjusted HR: 1.37 [95% CI:1.07-1.76], P = 0.01; adjusted HR: 1.43 [95% CI:1.13-1.82], P = 0.003).

CONCLUSION

RCA-CTO lesions, which had more complex angiographic features, independently contributed to TLR and TVR but not to MACEs or cardiac death in the 5 years of follow-up.

Who Should Undergo Chronic Total Occlusions Percutaneous Coronary Intervention and When?: An Evidence-Based Approach to the Patient Referred for Percutaneous Coronary Intervention of Chronic Total Occlusion

Chronic total occlusions (CTO) of the coronary arteries are common among patients presenting to the cardiac catheterization laboratory, and data suggests a worse overall prognosis in patients with CTOs. Percutaneous coronary intervention (PCI) of CTOs has been shown to improve anginal symptoms in observational studies and in a limited number of randomized trials. However, CTO PCI has not been shown to lead to a reduction in other important end points such as myocardial infarction or death. Furthermore, despite recent advances in the field, CTO PCI still carries higher risks and a lower likelihood of success compared with non-CTO PCI. Thus, determining which patients may be appropriate for CTO PCI is challenging and must involve a comprehensive risk-benefit analysis and discussion with the patient. Therefore, we review the currently available data regarding CTO PCI, including the clinical outcomes, the role of preprocedural ischemia testing, and various procedural success and risk stratification scores. Finally, we present our approach to the patient referred for CTO PCI.

Development and validation of a nomogram for major adverse cardiovascular events after chronic total occlusion percutaneous coronary intervention for ischemic heart failure

BACKGROUND

Chronic total occlusion percutaneous coronary intervention (CTO-PCI) is an available means of revascularization in patients with ischemic heart failure (IHF). However, the prognosis of IHF patients undergoing CTO-PCI remains unclear due to the lack of reliable clinical predictive tools.

AIM

This study aimed to establish a nomogram for major adverse cardiovascular events (MACE) after CTO-PCI in IHF patients.

METHODS

Sixty-seven potential predictive variables for MACE in 560 IHF patients undergoing CTO-PCI were screened using least absolute shrinkage and selection operator regression. A nomogram was constructed based on multivariable Cox regression to visualize the risk of MACE, and then evaluation was carried out using the concordance index (C-index), time-independent receiver operating characteristic (timeROC) curves, calibration curves, and decision curve analysis (DCA).

RESULTS

During a median follow-up of 32.0 months, there were 208 MACE occurrences. Seven variables were selected for nomogram construction: age, left ventricular ejection fraction, left ventricular end-diastolic diameter, N-terminal precursor B-type diuretic peptide, bending, and use of intravascular ultrasound and beta-blockers. The C-index was 0.715 (0.680-0.750) and the internal validation result was 0.715 (0.676-0.748). The timeROC area under the curve at 6 months, 1 year, and 2 years was 0.750 (0.653-0.846), 0.747 (0.690-0.804), and 0.753 (0.708-0.798), respectively. The calibration curves and DCA showed the nomogram had acceptable calibration and clinical applicability.

CONCLUSIONS

We developed a simple and efficient nomogram for MACE after CTO-PCI in IHF patients, which helps in early risk stratification and postoperative management optimization.

Efficacy of revascularization in CTO patients based on hibernating myocardium therapy

BACKGROUND

The effectiveness of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) is still uncertain, especially for patients with ischemic left ventricular dysfunction. This study aimed to assess hibernating myocardium (HM), as determined by single-photon emission computed tomography (SPECT) and 18F-FDG positron emission tomography (PET), and to compare the benefits of PCI and optimal medical therapy (OMT).

METHODS

A retrospective study collected data from 332 patients with CTO and ischemic left ventricular dysfunction. The study compared patients who underwent PCI or OMT via propensity score matching (PSM) analysis which was performed with a 1:2 matching protocol using the nearest neighbour matching algorithm. The primary endpoint of the study was the occurrence of major adverse cardiac events (MACE), defined as a composite of cardiac death, readmission for worsening heart failure (WHF), revascularization and myocardial infarction (MI).

RESULTS

After PSM, there were a total of 246 individuals in the PCI and OMT groups. Following Cox regression, hibernating myocardium/total perfusion defect (HM/TPD) was identified as an independent risk factor (hazard ratio (HR): 1.03, 95% confidence interval (CI): 1.008-1.052, p = .007). The cut-off value of HM/TPD was 38%. The results of the subgroup analysis suggest that for patients with HM/TPD >38%, the OMT group had a greater risk of MACE (p = .035). A sensitivity analysis restricting patients with single-vessel CTO lesions, HM/TPD remained an independent predictor (HR 1.025, 95% CI 1.008-1.043, p = .005).

CONCLUSION

HM/TPD is an independent predictor of MACE, and for patients with HM/TPD > 38%, CTO-PCI had a lower risk of MACE compared with OMT. However, further validation is still needed through large-scale studies.

N terminal pro-brain natriuretic peptide level and benefits of chronic total occlusion revascularization

BACKGROUND

The management of revascularization of chronic total occlusions (CTOs) remains controversial. Whether specific patients gain survival benefit from CTO revascularization remains unknown.

OBJECTIVES

We investigated whether (i) patients with CTO have higher N terminal pro-brain natriuretic peptide (NT pro-BNP) levels than patients without CTO, (ii) in patients with CTO, NT pro-BNP levels predict adverse events, and (iii) those with elevated levels benefit from revascularization.

METHODS

In 392 patients with stable, significant coronary artery disease (CAD) and CTO undergoing coronary angiography, rates of all-cause mortality, cardiovascular death, and a composite (cardiovascular death, myocardial infarction and heart failure hospitalizations) were investigated. Unadjusted and adjusted Cox proportional and Fine and Gray sub-distribution hazard models were performed to determine the association between NT pro-BNP levels and incident event rates in patients with CTO.

RESULTS

NT pro-BNP levels were higher in patients with, compared to those without CTO (median 230.0 vs. 177.7 pg/mL, p ≤0.001). Every doubling of NT pro-BNP level in patients with CTO was associated with a > 25% higher rate of adverse events. 111 (28.5%) patients underwent CTO revascularization. In patients with elevated NT pro-BNP levels (> 125 pg/mL), those who underwent CTO revascularization had substantially lower adverse event rates compared to patients without CTO revascularization (adjusted cardiovascular death hazard ratio 0.29, 95% confidence interval (0.09-0.88). However, in patients with low NT pro-BNP levels (≤ 125 pg/mL), event rates were similar in those with and without CTO revascularization.

CONCLUSION

NT pro-BNP levels can help identify individuals who may benefit from CTO revascularization.

Comparison of Complete Versus Incomplete Percutaneous Revascularization in Patients With Chronic Total Occlusion: A Systematic Review and Meta-Analysis

The optimal extent of revascularization in patients with chronic total occlusion (CTO) undergoing percutaneous coronary intervention (PCI) remains debated. This meta-analysis aimed to compare the clinical outcomes of complete versus incomplete revascularization in CTO patients. A systematic search of EMBASE, PubMed, and Web of Science was conducted up to July 6, 2024. Studies reporting outcomes in CTO patients undergoing PCI with complete or incomplete revascularization were included. The primary outcomes were major adverse cardiovascular events (MACE), all-cause mortality, and cardiovascular mortality. Eight studies with a total of 7,067 patients (4,854 complete and 2,213 incomplete revascularization) were included. Complete revascularization was associated with a significantly lower risk of MACE (RR: 0.57, 95% CI: 0.43-0.77), all-cause mortality (RR: 0.54, 95% CI: 0.37-0.78), and cardiovascular mortality (RR: 0.46, 95% CI: 0.29-0.75) compared to incomplete revascularization. There was no significant difference in the risk of recurrent myocardial infarction between the two groups (RR: 0.60, 95% CI: 0.20-1.80). In patients with CTO undergoing PCI, complete revascularization is associated with significantly better clinical outcomes, including lower risks of MACE, all-cause mortality, and cardiovascular mortality, compared to incomplete revascularization. These findings suggest that achieving complete revascularization should be prioritized when feasible in CTO patients.

Efficacy and safety of drug-coated balloons in chronic total coronary occlusion recanalization: a systematic review and meta-analysis

BACKGROUND

With advancements in chronic total coronary occlusion (CTO) recanalization techniques and concepts, the success rate of recanalization has been steadily increasing. However, the current data are too limited to draw any reliable conclusions about the efficacy and safety of drug-coated balloons (DCBs) in CTO percutaneous coronary intervention (PCI). Herein, we conducted a meta-analysis to confirm the efficacy of DCB in CTO PCI.

METHODS

We systematically searched PubMed, Web of Science and Embase from inception to July 25, 2023. The primary outcome was major advent cardiovascular events (MACE), including cardiac death, nonfatal myocardial infarction (MI), target lesion revascularization (TLR), and target vessel revascularization (TVR). The follow-up angiographic endpoints were late lumen enlargement (LLE), reocclusion and restenosis.

RESULTS

Five studies with a total of 511 patients were included in the meta-analysis. Across studies, patients were predominantly male (72.9-85.7%) and over fifty years old. The summary estimate rate of MACE was 13.0% (95% CI 10.1%-15.9%, I2 = 0%, p = 0.428). The summary estimate rates of cardiac death and MI were 2.2% (95% CI 0.7%-3.7%, I2 = 0%, p = 0.873) and 1.2% (95% CI -0.2-2.6%, I2 = 13.7%, p = 0.314), respectively. Finally, the pooled incidences of TLR and TVR were 10.1% (95% CI 5.7%-14.5%, I2 = 51.7%, p = 0.082) and 7.1% (95% CI 3.0%-11.2%, I2 = 57.6%, p = 0.070), respectively. Finally, the summary estimate rates of LLE, reocclusion and restenosis were 59.4% (95% CI 53.5-65.3%, I2 = 0%, p = 0.742), 3.3% (95% CI 1.1-5.4%, I2 = 0%, p = 0.865) and 17.5% (95% CI 12.9-22.0%, I2 = 0%, p = 0.623), respectively.

CONCLUSION

Accordingly, DCB has the potential to be used as a treatment for CTO in suitable patients.

Coronary Artery Bypass Grafting versus Percutaneous Coronary Intervention in Patients with Chronic Total Occlusion

OBJECTIVES

 Mechanisms of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) differ as CABG provides surgical collateralization and may prolong life by preventing future myocardial infarctions (MIs). However, evidence for CABG in patients with chronic total occlusion (CTO) has not been fully elucidated and the impact of PCI is discussed controversially.

METHODS

 We performed a meta-analysis of studies comparing outcomes in patients with/without multivessel disease undergoing CABG or PCI for CTO. The primary outcome was long-term all-cause mortality (≥5 years). Secondary outcomes were MIs, repeat revascularization, cardiac mortality, major adverse cardiovascular events, and stroke, as well as short-term mortality (30 days/in-hospital) and stroke. A pooled Kaplan-Meier survival curve after reconstruction analysis was generated. Random-effects models were used.

RESULTS

 Six studies totaling 12,504 patients were included. In the pooled Kaplan-Meier analysis, PCI showed a significantly higher risk of death in the follow-up compared with CABG (hazard ratio [HR]: 2.12, 95% confidence interval [CI]: 1.88-2.38, p < 0.01). During the observation period, PCI was also associated with higher rates of MI (odds ratio [OR]: 2.86, 95% CI: 1.82-4.48, p < 0.01) and more repeat revascularization (OR: 4.88, 95% CI: 1.99-11.91, p = 0.0005). The other outcomes did not show significant differences.

CONCLUSION

 CABG is associated with superior survival to PCI over time in patients with CTO who are eligible for both PCI and CABG. This survival advantage is associated with fewer events of MI and repeat revascularization.

Percutaneous Coronary Intervention versus Optimal Medical Therapy in Patients with Chronic Total Occlusion: A Meta-Analysis

Background/Objectives: Chronic total occlusion (CTO) is a prevalent finding in patients with coronary artery disease and is associated with increased mortality. Prior reports on the efficacy of percutaneous coronary intervention (PCI) compared to optimal medical therapy (OMT) were controversial. Following the emergence of recently published new evidence, a meta-analysis is warranted. The current meta-analysis assessed the effects of PCI compared to OMT in the treatment of CTO. Methods: A structured literature search was performed. Randomized controlled trials (RCTs) and non-randomized controlled studies of interventions were eligible. The primary outcome was an accumulated composite of cardiac mortality, myocardial infarction and target vessel/lesion revascularization events. Results: Thirty-two studies reporting on 11260 patients were included. Of these, 5712 (50.7%) were assigned to the PCI and 5548 (49.3%) were allocated to the OMT group. The primary outcome occurred in 14.6% of the PCI and 20.1% of the OMT group (12 trials, OR 0.66, 95% CI 0.50 to 0.88, p = 0.005, I2 = 67%). Subgrouping demonstrated a consistent reduction in the primary outcome for the PCI group in RCTs (six trials, OR 0.58, 95% CI 0.33 to 0.99, p = 0.05). The primary outcome reduction was irrespective of the study design, and it was replicable in sensitivity and subgroup analyses. Advantages in other outcomes were rather related to statistical pooling effects and dominated by observational data. Conclusions: CTO-PCI was associated with improved patient-oriented primary outcome compared to OMT in a study-level meta-analysis. This composite outcome effect was mainly driven by target vessel treatment, but a significant reduction in mortality and myocardial infarction was observed, irrespectively. These findings have hypothesis-generating implications. Future RCTs with adequate statistical power are eagerly awaited.

Percutaneous Coronary Intervention Offers Clinical Benefits to Diabetic Patients With Stable Chronic Total Occlusion

Whether percutaneous coronary intervention for chronic total occlusion (CTO-PCI) in diabetic patients offers more benefits compared with initial medical therapy (CTO-MT) is unclear. In this study, diabetic patients with one CTO (clinical manifestations: stable angina or silent ischemia) were enrolled. Consecutively, enrolled patients (n = 1605) were assigned to different groups: CTO-PCI (1044 [65.0%]) and initial CTO-MT (561 [35%]). After a median follow-up of 44 months, CTO-PCI tended to be superior to initial CTO-MT in major adverse cardiovascular events (adjusted hazard-ratio [aHR]: .81, 95% conference-interval: .65-1.02) and significantly superior in cardiac death (aHR: .58 [.39-.87]) and all-cause death (aHR: .678[.473-.970]). Such superiority mainly attributed to a successful CTO-PCI. CTO-PCI tended to be performed in patients with younger age, good collaterals, left anterior descending branch CTO, and right coronary artery CTO. While, those with left circumflex CTO and severe clinical/angiographic situations were more likely to be assigned to initial CTO-MT. However, none of these variables influenced the benefits of CTO-PCI. Thus, we concluded that for diabetic patients with stable CTO, CTO-PCI (mainly successful CTO-PCI) offered patients survival benefits over initial CTO-MT. These benefits were consistent regardless of clinical/angiographic characteristics.

Coronary Chronic Total Occlusion Revascularization: When, Who and How?

Coronary chronic total occlusions (CTO) are an increasingly frequent entity in clinical practice and represent a challenging percutaneous coronary intervention (PCI) scenario. Despite data from randomized trials that have not yet demonstrated a clear benefit of CTO recanalization, the widespread of CTO-PCI has substantially increased. The improvement in operators' techniques, equipment, and training programs has led to an improvement in the success rate and safety of these procedures, which will represent an important field of future development of PCI. The present review will summarize clinical outcomes and technical and safety issues of CTO revascularization with the aim to guide clinical daily cath-lab practice.

Long-Term Outcomes in Patients With Chronic Total Occlusion

Although a chronic total occlusion (CTO) in the setting of an acute coronary syndrome is associated with greater risk, the prognosis of patients with a CTO and stable coronary artery disease (CAD) remains unknown. This study aimed to investigate adverse event rates in patients with stable CAD with and without a CTO. In 3,597 patients with stable CAD (>50% coronary luminal stenosis) who underwent cardiac catheterization, all-cause mortality, cardiovascular mortality, and the composite major adverse cardiac event (MACE) rates for cardiovascular death, myocardial infarction, and heart failure hospitalization were evaluated. Cox proportional hazards and Fine and Gray subdistribution hazard models were used to compare event-free survival in patient subsets after adjustment for covariates. Event rates were higher in patients with CTOs than in those without CTOs after adjusting for demographic and clinical characteristics (cardiovascular death hazard ratio [HR] 1.29, 95% confidence interval [CI] 1.05 to 1.57, p = 0.012). Patients with CTO revascularization had lower event rates than those of patients without CTO revascularization (cardiovascular death HR 0.43, CI 0.26 to 0.70, p = 0.001). Those with nonrevascularized CTOs were at particularly great risk when compared with those without CTO (cardiovascular death HR 1.52, CI 1.25 to 1.84, p <0.001). Moreover, those with revascularized CTOs had similar event rates to those of patients with CAD without CTOs. Patients with CTO have higher rates of adverse cardiovascular events than those of patients with significant CAD without CTO. This risk is greatest in patients with nonrevascularized CTO.

Uric acid to high-density lipoprotein cholesterol ratio predicts adverse cardiovascular events in patients with coronary chronic total occlusion

BACKGROUND AND AIMS

Uric acid to high-density lipoprotein cholesterol ratio (UHR) is a novel index of metabolism and inflammation proposed by recent studies. The prognostic value of UHR is undetermined in patients with coronary chronic total occlusion (CTO). The aim of this study was to investigate the association of UHR with adverse cardiovascular events in patients with CTO.

METHODS AND RESULTS

In this retrospective cohort study, we enrolled 566 patients with CTO lesion in our hospital from January 2016 to December 2019. Patients were divided into three groups based on UHR level. The primary endpoint was major adverse cardiovascular event (MACE), defined as a combination of death, non-fatal MI, target vessel revascularization (TVR), and non-fatal stroke. The median follow-up time of this study was 43 months. During the follow-up, 107 (18.9%) MACEs were recorded. Kaplan-Meier survival plots show the cumulative incidence of MACE-free decreased across tertile of UHR (log-rank test, p < 0.001). In the fully adjusted model, the Hazard ratio (95% CI) of MACE was 2.16 (1.17-3.99) in tertile 3 and 2.01 (1.62-2.49) for per SD increase in UHR.

CONCLUSION

Elevated UHR predicts an increasing risk of MACE in patients with CTO. UHR is a simple and reliable indicator for risk stratification and early intervention in CTO patients.

Triglyceride-glucose index in the prediction of clinical outcomes after successful recanalization for coronary chronic total occlusions

BACKGROUND

Triglyceride-glucose index (TyG) has been widely used to predict cardiovascular outcomes. However, it remains unclear whether TyG holds prognostic significance for patients with coronary chronic total occlusions (CTO). Thus, our study aimed to evaluate the predictive accuracy and prognostic value of TyG in individuals who underwent successful percutaneous coronary intervention (PCI) for CTO.

METHODS

A total of 331 consecutive patients with ≥ 1 successful CTO-PCI were included. The baseline and angiographic data were acquired. The duration of follow-up ranged from 32 to 79 months, with a median of 44 months and an interquartile range of 39 to 67 months. The primary outcome measured was the occurrence of major adverse cardiac and cerebrovascular events (MACCE), including mortality, target vessel revascularization, recurrent myocardial infarction, and stroke.

RESULTS

After controlling for confounders, multivariate Cox regression analysis revealed that TyG remained statistically significant, regardless of being a continuous or categorical variable. In the partially adjusted regression model, the Hazard ratio (95%CI) for MACCE was 2.54 (1.12-5.79) in tertile 3 and 1.61 (1.22-2.12) per SD increase in the TyG.Kaplan-Meier survival analysis demonstrated significant differences in MACCE-free survival rates across tertiles of the TyG, as indicated by the log-rank test (p = 0.001). ROC analysis was conducted to evaluate the predictive ability of TyG for MACCE, resulting in an AUC of 0.677.

CONCLUSION

The TyG index demonstrates independent predictive capabilities for MACCE in patients who have undergone successful CTO-PCI. These findings suggest that TyG holds the potential as a valuable tool in risk stratification and the identification of patients who may benefit from early intervention in the management of CTO.

High Sensitivity Troponin Level and Benefits of Chronic Total Occlusion Revascularization

Background The survival benefit of revascularization of chronic total occlusion (CTO) of the coronary arteries remains a subject of controversy. We measured high sensitivity troponin-I (hsTn-I) levels as an estimate of myocardial ischemia in patients with stable coronary artery disease, with the hypothesis that (1) patients with CTO have higher levels of hsTn-I than patients without CTO, (2) hsTn-I levels will predict adverse cardiovascular events in patients with CTO, and (3) patients with elevated hsTn-I levels will have a survival benefit from CTO revascularization. Methods and Results In 428 patients with stable coronary artery disease and CTO undergoing coronary angiography, adverse event rates were investigated. Cox proportional hazards models and Fine and Gray subdistribution hazard models were performed to determine the association between hsTn-I level and incident event rates in patients with CTO. HsTn-I levels were higher in patients with compared with those without CTO (median 6.7 versus 5.6 ng/L, P=0.002). An elevated hsTn-I level was associated with higher adverse event rates (adjusted all-cause mortality hazard ratio, 1.19 [95% CI, 1.08-1.32]; P=0.030) for every doubling of hsTn-I level. CTO revascularization was performed in 28.3% of patients. In patients with a high (>median) hsTn-I level, CTO revascularization was associated with substantially lower all-cause mortality (adjusted hazard ratio, 0.26 [95% CI, 0.08-0.88]; P=0.030) compared with those who did not undergo revascularization. In patients with a low ( Collapse

Key Words

• chronic total occlusion
• coronary artery bypass graft
• high sensitivity troponin‐I
• percutaneous coronary intervention

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MESH Headings

• Humans
• Coronary Artery Disease/complications
• Coronary Occlusion
• Risk Factors
• Treatment Outcome
• Percutaneous Coronary Intervention/adverse effects
• Coronary Angiography/adverse effects
• Chronic Disease
• Troponin I

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Grants

• U54 AG062334 NIA NIH HHS
• P01 HL154996 NHLBI NIH HHS
• R33 HL138657 NHLBI NIH HHS
• P01 HL086773 NHLBI NIH HHS
• P30 DK111024 NIDDK NIH HHS
• R01 HL109413 NHLBI NIH HHS
• R01 HL166004 NHLBI NIH HHS
• R61 HL154116 NHLBI NIH HHS
• P20 HL113451 NHLBI NIH HHS
• P01 HL101398 NHLBI NIH HHS

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Affiliation(s)

Daniel A. Gold Division of Cardiology, Department of MedicineEmory Clinical Cardiovascular Research Institute, Emory University School of MedicineAtlantaGA
Pratik B. Sandesara Division of Cardiology, Department of MedicineEmory Clinical Cardiovascular Research Institute, Emory University School of MedicineAtlantaGA
Vardhmaan Jain Division of Cardiology, Department of MedicineEmory Clinical Cardiovascular Research Institute, Emory University School of MedicineAtlantaGA
Matthew E. Gold Division of Cardiology, Department of MedicineEmory Clinical Cardiovascular Research Institute, Emory University School of MedicineAtlantaGA
Nishant Vatsa Division of Cardiology, Department of MedicineEmory Clinical Cardiovascular Research Institute, Emory University School of MedicineAtlantaGA
Shivang R. Desai Division of Cardiology, Department of MedicineEmory Clinical Cardiovascular Research Institute, Emory University School of MedicineAtlantaGA
Malika Elhage Hassan Division of Cardiology, Department of MedicineEmory Clinical Cardiovascular Research Institute, Emory University School of MedicineAtlantaGA
Chenyang Yuan Department of Biostatistics and Bioinformatics, Rollins School of Public HealthEmory UniversityAtlantaGA
Yi‐An Ko Department of Biostatistics and Bioinformatics, Rollins School of Public HealthEmory UniversityAtlantaGA
Ayman Alkhoder Division of Cardiology, Department of MedicineEmory Clinical Cardiovascular Research Institute, Emory University School of MedicineAtlantaGA
Kiran Ejaz Division of Cardiology, Department of MedicineEmory Clinical Cardiovascular Research Institute, Emory University School of MedicineAtlantaGA
Zain Alvi Division of Cardiology, Department of MedicineEmory Clinical Cardiovascular Research Institute, Emory University School of MedicineAtlantaGA
Alireza Rahbar Division of Cardiology, Department of MedicineEmory Clinical Cardiovascular Research Institute, Emory University School of MedicineAtlantaGA
Gillian Murtagh Abbott Diagnostics, Abbott LaboratoriesAbbott ParkIL
Wissam A. Jaber Division of Cardiology, Department of MedicineEmory Clinical Cardiovascular Research Institute, Emory University School of MedicineAtlantaGA
William J. Nicholson Division of Cardiology, Department of MedicineEmory Clinical Cardiovascular Research Institute, Emory University School of MedicineAtlantaGA
Arshed A. Quyyumi Division of Cardiology, Department of MedicineEmory Clinical Cardiovascular Research Institute, Emory University School of MedicineAtlantaGA

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Percutaneous Coronary Intervention versus Coronary Artery Bypass Grafting for Chronic Total Occlusion of Coronary Arteries: A Systematic Review and Meta-Analysis

Introduction

Chronic total occlusion (CTO) of coronary arteries constitutes a substantial clinical challenge and has historically been managed through medical management and coronary artery bypass grafting (CABG). However, with the advancement in interventional technology, the success rate of percutaneous treatment has been significantly improved, and percutaneous coronary intervention (PCI) has emerged as a primary mode of treatment for CTOs, demonstrating remarkable clinical efficacy. The objective of this systematic review and meta-analysis is to evaluate and contrast the outcomes of PCI and CABG in patients with CTO.

Methods and Results

A systematic search was conducted in the databases of PubMed, Embase, and Web of Science. The primary endpoints evaluated in this meta-analysis were the occurrence of major adverse cardiac events (MACE) and all-cause mortality. Secondary endpoints included myocardial infarction (MI), cardiac death, and the need for repeat revascularization. Nine studies, encompassing a total of 8,674 patients, were found to meet the criteria for inclusion and had a mean follow-up duration of 4.3 years. The results of the meta-analysis revealed that compared to CABG, PCI was associated with a lower incidence of all-cause mortality (RR: 0.78, 95% CI: 0.66-0.92; P = 0.003) and cardiac death (RR: 0.55; 95% CI: 0.31-0.96; P < 0.05), but an increased risk of myocardial infarction (MI) (RR: 1.96; 95%CI: 1.07-3.62; P < 0.05) and repeat revascularization (RR: 7.13; 95% CI: 5.69-8.94; P < 0.00001). There was no statistically significant difference in MACE (RR: 1.11; 95% CI: 0.69-1.81; P = 0.66) between the PCI and CABG groups.

Conclusion

In the present meta-analysis comparing PCI and CABG in patients with chronic total occlusion of the coronary arteries, the results indicated that PCI was superior to CABG in reducing all-cause mortality and cardiac death but inferior in decreasing myocardial infarction and repeat revascularization. There was no statistically significant difference in MACE between the two groups.

Baseline angina burden predicts quality of life and functional improvement in patients with viable myocardium treated for chronic total occlusion

Chronic total occlusion (CTO) is a common finding in patients with known or suspected coronary artery disease and has a distinctive role in these patients' quality of life. However, there is still a lack of evidence of correct patient selection for percutaneous coronary intervention (PCI). From July 2017 to August 2020, 68 patients with successful PCI of a CTO and previous evidence of viability for PCI by cardiovascular magnetic resonance imaging (CMR) were prospectively included in this single-centre observational study. Of these patients, 62 underwent follow-up CMR, and 56 underwent surveys using the Seattle Angina Questionnaire before PCI and 3, 12 and 24 months after PCI. The CMR results were assessed for volumetric, functional and deformation parameters. From the baseline to the follow-up, there was a significant reduction in the left ventricular volumes (all p < 0.001) and an increase in the left ventricular ejection fraction (57.6 ± 11.6% vs. 60.3 ± 9.4%, p = 0.006). Among the deformation parameters, only the left ventricular radial strain showed significant improvement. The SAQ showed an early improvement that emphasised angina stability and frequency as well as a summary score, which persisted after 24 months. A low SAQ summary score before PCI was the best predictive factor of good clinical improvement thereafter. Improvements in myocardial function and quality of life can be achieved with PCI of a CTO. Patient selection for PCI should be performed primarily among relevantly symptomatic patients when evidence of viability for PCI is present. The SAQ can help guide such patient selection.Trial registration ISRCTN, identifier: ISRCTN33203221. Retrospectively registered on 01.04.2020. https://www.isrctn.com/ISRCTN33203221.

Short- and Long-term Outcomes of Percutaneous Coronary Interventions in Chronic and Non-chronic Total Occlusions: A Meta-analysis of 690,123 Patients

The use of percutaneous coronary intervention (PCI) in patients with chronic total occlusion (CTO) is still a subject of debate, with conflicting outcomes reported in different studies when compared to non-CTO lesions. This meta-analysis aims to clarify the clinical outcomes of PCI in CTO cases compared to non-CTO lesions, both in the short and long-term. PubMed, Scopus, Web of Science, Ovid, and Cochrane Central were searched until March 2023 for relevant studies addressing short- and long-term outcomes of PCI in CTO vs non-CTO lesions. Dichotomous data were pooled as odds ratio (OR) with its 95% confidence interval (CI) in a random Der-Simonian lair effect model using STATA 17 MP. Eight studies with a total of 690,123 patients were included. In terms of short-term outcomes, CTO PCI was associated with higher rates of vessel perforation (OR = 2.16, 95% CI: 1.31-3.57) and cardiac tamponade (OR = 5.19, 95% CI: 4.29-6.28). Additionally, CTO PCI showed lower rates of procedural success (OR = 0.84, 95% CI: 0.73-0.96). Moreover, in the long-term, CTO PCI had higher rates of MACE (OR = 1.02, 95% CI: 1.01-1.04), however, it showed lower rates of cardiac death (OR = 0.61, 95% CI: 0.38-0.98), with no significant difference in other reported outcomes. Our findings underscore the challenges and adverse outcomes associated with using PCI to treat CTO lesions in the short term. This suggests that interventional cardiologists should carefully evaluate the risks and benefits before proceeding with PCI in CTO lesions.

Association of Successful Percutaneous Revascularization of Chronic Total Occlusions With Quality of Life: A Systematic Review and Meta-Analysis

Importance

Chronic total occlusion percutaneous coronary intervention (CTO-PCI) is not usually offered because of skepticism about long-term clinical benefits.

Objective

To assess the association of successful CTO-PCI with quality of life by analyzing the relevant domains of the Seattle Angina Questionnaire (SAQ).

Data Sources

PubMed, EMBASE, Web of Science, Google Scholar, and Cochrane databases were searched to identify randomized trials and observational studies specifically addressing quality of life domains of SAQ from January 2010 to June 2022.

Study Selection

Studies included reporting SAQ metrics such as angina frequency, physical limitation, and quality of life, before and after CTO-PCI.

Data Extraction and Synthesis

The present study was performed according to the Cochrane Collaboration and Preferred Reporting Items for Systematic Reviews and Meta-Analyses statements, in which fixed-effect or random-effect models with generic inverse-variance weighting depending on statistical homogeneity were applied. Data were extracted by 3 independent reviewers.

Outcomes and Measures

The primary outcome was angina frequency; physical limitation and quality of life were assessed as secondary outcomes.

Results

Seven prospective randomized or observational studies (2500 patients) were included, with a mean (SD) participant age of 61.2 (2.1) years. CTO-PCI was associated with significantly improved quality-of-life metrics during a mean (SD) follow-up of 14.8 (16.3) months. In patients with successful procedures, angina episodes became less frequent (mean [SD] difference for SAQ angina frequency of 12.9 [3.1] survey points [95% CI, 7.1-19.8 survey points]; standardized mean difference was 0.54 [95% CI, 0.21-0.92]; P = .002; I2 = 86.4%) and they experienced less physical activity limitation (mean [SD] difference for SAQ physical limitation of 9.7 [6.2] survey points [95% CI, 3.5-16.2 survey points]; standardized mean difference was 0.42 [95% CI, 0.24-0.55]; P < .001; I2 = 20.9%), and greater quality-of-life domain (mean [SD] difference for SAQ quality of life of 14.9 [3.5] survey points [95% CI, 7.7-22.5 survey points]; standardized mean difference was 0.41 [95% CI, 0.25-0.61]; P < .001; I2 = 58.8%) compared with patients with optimal medical therapy or failed procedure. Furthermore, follow-up duration (point estimate, 0.03; 95% CI, 0.01-0.04; P = .01) was associated with a significant decrease in angina frequency in meta-regression analysis.

Conclusions and Relevance

In this systematic review and meta-analysis examining quality of life following CTO-PCI, successful procedures were associated with improved quality-of-life parameters compared with patients on optimal medical therapy or after failed CTO-PCI. These findings suggest support for using PCI to treat CTOs in symptomatic patients unresponsive to medical treatment.

Effect of complete percutaneous revascularization on improving long-term outcomes of patients with chronic total occlusion and multi-vessel disease

BACKGROUND

Limited data are available on the comparison of clinical outcomes of complete vs. incomplete percutaneous coronary intervention (PCI) for patients with chronic total occlusion (CTO) and multi-vessel disease (MVD). The study aimed to compare their clinical outcomes.

METHODS

A total of 558 patients with CTO and MVD were divided into the optimal medical treatment (OMT) group ( n = 86), incomplete PCI group ( n = 327), and complete PCI group ( n = 145). Propensity score matching (PSM) was performed between the complete and incomplete PCI groups as sensitivity analysis. The primary outcome was defined as the occurrence of major adverse cardiovascular events (MACEs), and unstable angina was defined as the secondary outcome.

RESULTS

At a median follow-up of 21 months, there were statistical differences among the OMT, incomplete PCI, and complete PCI groups in the rates of MACEs (43.0% [37/86] vs. 30.6% [100/327] vs. 20.0% [29/145], respectively, P = 0.016) and unstable angina (24.4% [21/86] vs. 19.3% [63/327] vs. 10.3% [15/145], respectively, P = 0.010). Complete PCI was associated with lower MACE compared with OMT (adjusted hazard ratio [HR] = 2.00; 95% confidence interval [CI] = 1.23-3.27; P = 0.005) or incomplete PCI (adjusted HR = 1.58; 95% CI = 1.04-2.39; P = 0.031). Sensitivity analysis of PSM showed similar results to the above on the rates of MACEs between complete PCI and incomplete PCI groups (20.5% [25/122] vs. 32.6% [62/190], respectively; adjusted HR = 0.55; 95% CI = 0.32-0.96; P = 0.035) and unstable angina (10.7% [13/122] vs. 20.5% [39/190], respectively; adjusted HR = 0.48; 95% CI = 0.24-0.99; P = 0.046).

CONCLUSIONS

For treatment of CTO and MVD, complete PCI reduced the long-term risk of MACEs and unstable angina, as compared with incomplete PCI and OMT. Complete PCI in both CTO and non-CTO lesions can potentially improve the prognosis of patients with CTO and MVD.

Computed Tomography Radiomics Model Predicts Procedure Success of Coronary Chronic Total Occlusions

BACKGROUND

Coronary computed tomography (CT) angiography imaging is useful for the preprocedural evaluation of chronic total occlusion (CTO). However, the predictive value of CT radiomics model for successful percutaneous coronary intervention (PCI) has not been studied. We aimed to develop and validate a CT radiomics model for predicting PCI success of CTOs.

METHODS

In this retrospective study, a radiomics-based model for predicting PCI success was developed on the training and internal validation sets of 202 and 98 patients with CTO, collected from 1 tertiary hospital. The proposed model was validated on an external test set of 75 CTO patients enrolled from another tertiary hospital. CT radiomics features of each CTO lesion were manually labeled and extracted. Other anatomical parameters, including occlusion length, entry morphology, tortuosity, and calcification burden, were also measured. Fifteen radiomics features, 2 quantitative plaque features, and CT-derived Multicenter CTO Registry of Japan score were used to train different models. The predictive values of each model were evaluated for predicting revascularization success.

RESULTS

In the external test set, 75 patients (60 men; 65 years [58.5, 71.5]) with 83 CTO lesions were assessed. Occlusion length was shorter (13.00 mm versus 29.30 mm, P=0.007) in PCI success group whereas the presence of tortuous course was more commonly presented in PCI failure group (1.49% versus 25.00%, P=0.004). The radiomics score was significantly smaller in PCI success group (0.10 versus 0.55, P<0.001). The area under the curve of CT radiomics-based model was significantly higher than that of CT-derived Multicenter CTO Registry of Japan score for predicting PCI success (area under the curve=0.920 versus 0.752, P=0.008). The proposed radiomics model accurately identified 89.16% (74/83) CTO lesions with procedure success.

CONCLUSIONS

CT radiomics-based model outperformed CT-derived Multicenter CTO Registry of Japan score for predicting PCI success. The proposed model is more accurate than the conventional anatomical parameters to identify CTO lesions with PCI success.

Long-term outcomes of less drug-eluting stents by the use of drug-coated balloons in de novo coronary chronic total occlusion intervention: A multicenter observational study

Background

Data on drug-coated balloons (DCB) for de novo coronary chronic total occlusion (CTO) are limited. We aimed to investigate the long-term outcomes of substitution of drug-eluting stents (DES) by DCB.

Methods

We compared the outcomes of less DES strategy (DCB alone or combined with DES) and DES-only strategy in treating de novo coronary CTO in this prospective, observational, multicenter study. The primary endpoints were major adverse cardiovascular events (MACE), target vessel revascularization, myocardial infarction, and death during 3-year follow-up. The secondary endpoints were late lumen loss (LLL) and restenosis until 1-year after operation.

Results

Of the 591 eligible patients consecutively enrolled between January 2015 and December 2019, 281 (290 lesions) were treated with DCB (DCB-only or combined with DES) and 310 (319 lesions) with DES only. In the DCB group, 147 (50.7%) lesions were treated using DCB-only, and the bailout stenting rate was relatively low (3.1%). The average stent length per lesion in the DCB group was significantly shorter compared with the DES-only group (21.5 ± 25.5 mm vs. 54.5 ± 26.0 mm, p < 0.001). A total of 112 patients in the DCB group and 71 patients in the DES-only group (38.6% vs. 22.3%, p < 0.001) completed angiographic follow-up until 1-year, and LLL was much less in the DCB group (-0.08 ± 0.65 mm vs. 0.35 ± 0.62 mm, p < 0.001). There were no significant differences in restenosis occurrence between the two groups (20.5% vs. 19.7%, p > 0.999). The Kaplan-Meier estimates of MACE at 3-year (11.8% vs. 12.0%, log-rank p = 0.688) was similar between the groups.

Conclusion

Percutaneous coronary intervention with DCB is a potential "stent-less" therapy for de novo CTO lesions with satisfactory long-term clinical results compared to the DES-only approach.

Good coronary collateral circulation is not associated with better prognosis in patients with chronic total occlusion, regardless of treatment strategy

OBJECTIVE

This study aimed to assess the effects of coronary collateral circulation (CCC) on the prognosis of patients with chronic total occlusion (CTO) under different treatment strategies.

METHODS

We analyzed a total of 1124 patients who were diagnosed with CTO and divided them into groups with good CCC (grade 2 to 3, n = 539) or poor CCC (grade 0 to 1, n = 531). The primary outcome was cardiac death during follow-up; the secondary outcome was major adverse cardiovascular events (MACEs). We also performed subgroup analyses in groups with and without CTO revascularization (CTO-R and CTO-NR, respectively), and sensitivity analyses excluding patients who received failed CTO-PCI to further investigate the effect of CCC.

RESULTS

During a median follow-up duration of 23 months, we did not detect any significant differences between the good CCC group and the poor CCC group in terms of cardiac death (4.2% vs 4.1%; adjusted hazard ratio [HR], 1.01; 95% confidence interval [CI], 0.56-1.83; p = 0.970) and MACEs (23.6% vs 23.2%; adjusted HR, 1.07; 95% CI, 0.84-1.37; p = 0.590). Subgroup analyses according to CTO revascularization showed similar results. In addition, we observed no differences in sensitivity analyses when patients who received failed CTO-PCI were excluded.

CONCLUSION

Good CCC was not associated with a lower risk of cardiac death or MACEs among patients with CTO, regardless of whether the patients received CTO revascularization treatment.

Percutaneous coronary intervention improves quality of life of patients with chronic total occlusion and low estimated glomerular filtration rate

Background

A low estimated glomerular filtration rate (eGFR <90 mL/min/1.73 m²) is widely recognized as a risk factor for major adverse cardiac events (MACE) after percutaneous coronary intervention (PCI) for chronic total occlusion (CTO). However, the impact of successful CTO-PCI on quality of life (QOL) of patients with low eGFR remains unknown.

Objectives

The aim of this prospective study was to assess the QOL of CTO patients with low eGFR after successful PCI.

Methods

Consecutive patients undergoing elective CTO-PCI were prospectively enrolled and subdivided into four groups: eGFR ≥90 mL/min/1.73 m² (n = 410), 90 > eGFR ≥ 60 mL/min/1.73 m² (n = 482), 60 > eGFR ≥ 30 mL/min/1.73 m² (n = 161), and eGFR <30 mL/min/1.73 m² (n = 23). The primary outcomes included QOL, as assessed with the European Quality of Life-5 Dimensions (EQ-5D) questionnaire, and symptoms, as assessed with the Rose Dyspnea Scale (RDS) and Seattle Angina Questionnaire (SAQ), at 1 month and 1 year after successful PCI.

Results

With the decline of eGFR, CTO patients were more likely to present with comorbidities of hypertension, diabetes, hyperuricemia, and previous stroke, in addition to lower hemoglobin levels and left ventricular ejection fraction (p < 0.05). Low eGFR was associated with greater incidences of in-hospital pericardiocentesis, major bleeding, acute renal failure, and subcutaneous hematoma, but not in-hospital MACE (p < 0.05). Symptoms of dyspnea and angina were alleviated in all CTO patients with eGFR ≥30 mL/min/1.73 m² at 1 month and 1 year after successful CTO-PCI, but only at 1 month for those with eGFR <30 mL/min/1.73 m² (p < 0.01). Importantly, QOL was markedly improved at 1 month and 1 year after successful PCI (p < 0.01), notably at a similar degree between patients with low eGFR and those with normal eGFR (p > 0.05).

Conclusion

Successful PCI effectively improved symptoms and QOL of CTO patients with low eGFR.

Benefits of successful percutaneous coronary intervention in chronic total occlusion patients with diabetes

BACKGROUND

Diabetes was commonly seen in chronic total occlusion (CTO) patients but data regarding the impact of successful percutaneous coronary intervention (PCI) on clinical outcome of CTO patients with diabetes was controversial. And importantly, no studies have compared quality of life (QOL) after CTO-PCI in patients with and without diabetes.

METHODS

Consecutive patients undergoing elective CTO-PCI were prospectively enrolled from Apr. 2018 to May 2021. Patients were subdivided into 2 groups: Diabetes and No Diabetes. Detailed baseline characteristics, assessment of symptoms and QOL, angiographic and procedural details, in-hospital complications, and 1 month and 1 year follow-up data were collected. These data were analyzed accordingly for risk predictors of clinical outcome in patients who have diabetes and received successful CTO-PCI.

RESULTS

A total of 1076 patients underwent CTO-PCI attempts. Diabetes was present in 374 (34.76%) patients, who had more hypertension, previous PCI and stroke. Regarding the coronary lesions, diabetic patients suffered more LCX lesion, multivessel disease, number of lesions per patient, blunt stump, calcification and higher J-CTO score (p < 0.05). In-hospital major adverse cardiac event (MACE) (4.13% vs. 5.35%; p = 0.362) was similar in the two groups. At 1 month and 1 year follow-up after successful CTO-PCI, the incidence of MACE and all-cause mortality were also similar in the two groups (p > 0.05). Number of lesions per patient was an independent risk factor of MACE and all-cause mortality (p < 0.001) 1 year after successful CTO-PCI. Symptom and QOL were markedly improved regardless of diabetes both at 1 month and 1 year follow-up, and importantly, patients with diabetes showed similar degrees of improvement to those without diabetes (P > 0.05).

CONCLUSIONS

Successful CTO-PCI could represent an effective strategy improving clinical outcome, symptoms and QOL in CTO patients with diabetes.

Pre-procedural planning of coronary revascularization by cardiac computed tomography: An expert consensus document of the Society of Cardiovascular Computed Tomography

Coronary CT angiography (CCTA) demonstrated high diagnostic accuracy for detecting coronary artery disease (CAD) and a key role in the management of patients with low-to-intermediate pretest likelihood of CAD. However, the clinical information provided by this noninvasive method is still regarded insufficient in patients with diffuse and complex CAD and for planning percutaneous coronary intervention (PCI) and surgical revascularization procedures. On the other hand, technology advancements have recently shown to improve CCTA diagnostic accuracy in patients with diffuse and calcific stenoses. Moreover, stress CT myocardial perfusion imaging (CT-MPI) and fractional flow reserve derived from CCTA (CT-FFR) have been introduced in clinical practice as new tools for evaluating the functional relevance of coronary stenoses, with the possibility to overcome the main CCTA drawback, i.e. anatomical assessment only. The potential value of CCTA to plan and guide interventional procedures lies in the wide range of information it can provide: a) detailed evaluation of plaque extension, volume and composition; b) prediction of procedural success of CTO PCI using scores derived from CCTA; c) identification of coronary lesions requiring additional techniques (e.g., atherectomy and lithotripsy) to improve stent implantation success by assessing calcium score and calcific plaque distribution; d) assessment of CCTA-derived Syntax Score and Syntax Score II, which allows to select the mode of revascularization (PCI or CABG) in patients with complex and multivessel CAD. The aim of this Consensus Document is to review and discuss the available data supporting the role of CCTA, CT-FFR and stress CT-MPI in the preprocedural and possibly intraprocedural planning and guidance of myocardial revascularization interventions.

Pre-procedural planning of coronary revascularization by cardiac computed tomography: An expert consensus document of the Society of Cardiovascular Computed Tomography

Coronary CT angiography (CCTA) demonstrated high diagnostic accuracy for detecting coronary artery disease (CAD) and a key role in the management of patients with low-to-intermediate pretest likelihood of CAD. However, the clinical information provided by this noninvasive method is still regarded insufficient in patients with diffuse and complex CAD and for planning percutaneous coronary intervention (PCI) and surgical revascularization procedures. On the other hand, technology advancements have recently shown to improve CCTA diagnostic accuracy in patients with diffuse and calcific stenoses. Moreover, stress CT myocardial perfusion imaging (CT-MPI) and fractional flow reserve derived from CCTA (CT-FFR) have been introduced in clinical practice as new tools for evaluating the functional relevance of coronary stenoses, with the possibility to overcome the main CCTA drawback, i.e. anatomical assessment only. The potential value of CCTA to plan and guide interventional procedures lies in the wide range of information it can provide: a) detailed evaluation of plaque extension, volume and composition; b) prediction of procedural success of CTO PCI using scores derived from CCTA; c) identification of coronary lesions requiring additional techniques (e.g., atherectomy and lithotripsy) to improve stent implantation success by assessing calcium score and calcific plaque distribution; d) assessment of CCTA-derived Syntax Score and Syntax Score II, which allows to select the mode of revascularization (PCI or CABG) in patients with complex and multivessel CAD. The aim of this Consensus Document is to review and discuss the available data supporting the role of CCTA, CT-FFR and stress CT-MPI in the preprocedural and possibly intraprocedural planning and guidance of myocardial revascularization interventions.

Why and How Should We Treat Chronic Total Occlusion? Evolution of State-of-the-Art Methods and Future Directions

Chronic total occlusions are considered the most complex coronary lesion in interventional cardiology. The absence of visible lumen on angiography obscures the vessel course and makes vessel wiring unlikely with conventional techniques. Often a source of severe ischemia, chronic occlusions are also markers of advanced atherosclerosis that brings other complex features including lesion length, bifurcations, calcification, adverse vessel remodelling, distal disease, and anatomic distortion from previous bypass grafting. Often advanced atherosclerosis is associated with patient characteristics like left ventricular dysfunction, previous coronary bypass surgery, or multivessel disease that increase procedural demands and hazards. To accommodate these challenges new techniques and dedicated technologies have been developed. When applied to appropriate patients, these advances have improved procedural success, safety, and outcomes. Our aim is to provide the general cardiologist with an overview of these advances that can serve as a basis for counselling patients considered for revascularization.

Recanalisation of coronary chronic total occlusions

Percutaneous treatment of coronary chronic total occlusions (CTO) has advanced greatly since its advent in the late 1970s through the development of dedicated wires and microcatheters, the improved skills of highly experienced operators and the adoption of new sophisticated strategies to guide procedural planning. The contemporary procedural success rate is 80-90% with a reduction in complications. Although there has been no improvement in prognosis in randomised trials to date, they, and other controlled registries of thousands of patients, confirm the pivotal role of CTO recanalisation in the treatment of angina and dyspnoea and an improvement in quality of life. Despite this evidence, CTO recanalisation is grossly underutilised. This review reports a detailed overview of the history, indications and treatment strategies for CTO recanalisation and hopes to increase interest among new, and especially young, operators in this demanding, rapidly evolving field of interventional cardiology.

Revascularization of chronic total occlusion coronary artery and cardiac regeneration

Coronary chronic total occlusion (CTO) contributes to the progression of heart failure in patients with ischemic cardiomyopathy. Randomized controlled trials demonstrated that percutaneous coronary intervention (PCI) for CTO significantly improves angina symptoms and quality of life but fails to reduce clinical events compared with optimal medical therapy. Even so, intervening physicians strongly support CTO-PCI. Cardiac regeneration therapy after CTO-PCI should be a promising approach to improving the prognosis of ischemic cardiomyopathy. However, the relationship between CTO revascularization and cardiac regeneration has rarely been studied, and experimental studies on cardiac regeneration usually employ rodent models with permanent ligation of the coronary artery rather than reopening of the occlusive artery. Limited early-stage clinical trials demonstrated that cell therapy for cardiac regeneration in ischemic cardiomyopathy reduces scar size, reverses cardiac remodeling, and promotes angiogenesis. This review focuses on the status quo of CTO-PCI in ischemic cardiomyopathy and the clinical prospect of cardiac regeneration in this setting.

Impact of Subintimal Plaque Modification on Reattempted Chronic Total Occlusions Percutaneous Coronary Intervention

BACKGROUND

Predictors of success in reattempted chronic total occlusion (CTO) percutaneous coronary intervention (PCI) procedures remain obscure, mainly owing to the lack of consecutive angiograms and procedural records of initial attempts in the same cohort.

OBJECTIVES

This study sought to investigate the factors predicting the success of reattempted CTO PCI procedures.

METHODS

A total of 208 consecutive patients who underwent a failed CTO PCI attempt and received reattempted procedure at the same cardiac center were retrospectively analyzed. Predictors of the success of reattempted procedures were evaluated.

RESULTS

The overall technical success rate of reattempted CTO PCI procedures was 71.2%. Subintimal plaque modification (SPM) was implemented in 35 (16.8%) procedures in initial attempts. The reattempted technical success rate was 93.3% in cases in which SPM with guidewire (GW) crossing was achieved in the initial attempt; however, the success rate was 55.0% for procedures involving SPM without GW crossing. SPM with GW crossing (OR: 11.21; 95% CI: 1.31-96.16; P = 0.028), referral to high-volume operators (OR: 2.38; 95% CI: 1.14-4.98; P = 0.021), and a bidirectional approach (OR: 2.31; 95% CI: 1.12-4.79; P = 0.024) were positive independent predictors of technical success in the subsequent reattempt. The time interval for reattempt (per 90-day increment) was negatively correlated with the technical success of the reattempted procedures (OR: 0.85; 95% CI: 0.73-0.98; P = 0.030).

CONCLUSIONS

This study identified independent predictors of success in reattempted CTO PCI procedures. SPM with GW crossing achieved in the initial attempt is associated with a higher success rate in the subsequent reattempt.

Risk Burden of Coronary Perforation in Chronic Total Occlusion Recanalization: Latin American CTO Registry Analysis

Background

Coronary perforation is a life‐threatening complication of acute percutaneous coronary intervention (PCI) for chronic total occlusions (CTO), but data on midterm outcomes are limited.

Methods and Results

Data from LATAM (Latin American)‐CTO Registry (57 centers; 9 countries) were analyzed. We assessed the risk of 30‐day, 1‐year major adverse cardiac events of coronary perforation using time‐to‐event and weighted composite end point analysis having CTO PCI without perforation as comparators. Additionally, we studied the independent predictors of perforation in these patients. Of 2054 patients who underwent CTO PCI between 2015 and 2018, the median Multicenter CTO Registry in Japan and Prospective Global Registry for the Study of Chronic Total Occlusion Intervention‐Chronic total occlusions scores were 2.0 (1.0–3.0) and 1.0 (0.0–2.0), respectively. The perforation rate was 3.7%, of which 55% were Ellis class 1. After 1‐year coronary perforation had higher major adverse cardiac events rates (24.9% versus 13.3%; P<0.01). Using weighted composite end point, perforation was associated with increased bleeding and ischemic events at 6 months (P=0.04) and 1 year (P<0.01). We found as independent predictors associated with coronary perforation during CTO PCI: maximum activated clotting time (P<0.01), Multicenter CTO Registry in Japan score ≥2 (P=0.05), antegrade knuckle wire (P=0.04), and right coronary artery CTO PCI (P=0.05).

Conclusions

Coronary perforation was infrequent and associated with anatomical and procedural complexity, resulting in higher risk of hemorrhagic and ischemic events. Landmark and weighted analysis showed a sustained burden of major events between 6 months and 1 year follow‐up.

Predicting Residual Angina After Chronic Total Occlusion Percutaneous Coronary Intervention: Insights from the OPEN-CTO Registry

Background Given that percutaneous coronary intervention (PCI) of a chronic total occlusion (CTO) is indicated primarily for symptom relief, identifying patients most likely to benefit is critically important for patient selection and shared decision-making. Therefore, we identified factors associated with residual angina frequency after CTO PCI and developed a model to predict postprocedure anginal burden. Methods and Results Among patients in the OPEN-CTO (Outcomes, Patient Health Status, and Efficiency in Chronic Total Occlusion Hybrid Procedures) registry, we evaluated the association between patient characteristics and residual angina frequency at 6 months, as assessed by the Seattle Angina Questionnaire Angina Frequency Scale. We then constructed a prediction model for angina status after CTO PCI using ordinal regression. Among 901 patients undergoing CTO PCI, 28% had no angina, 31% had monthly angina, 30% had weekly angina, and 12% had daily angina at baseline. Six months later, 53% of patients had a ≥20-point increase in Seattle Angina Questionnaire Angina Frequency Scale score. The final model to predict residual angina after CTO PCI included baseline angina frequency, baseline nitroglycerin use frequency, dyspnea symptoms, depressive symptoms, number of antianginal medications, PCI indication, and presence of multiple CTO lesions and had a C index of 0.78. Baseline angina frequency and nitroglycerin use frequency explained 71% of the predictive power of the model, and the relationship between model components and angina improvement at 6 months varied by baseline angina status. Conclusions A 7-component OPEN-AP (OPEN-CTO Angina Prediction) score can predict angina improvement and residual angina after CTO PCI using variables commonly available before intervention. These findings have implications for appropriate patient selection and counseling for CTO PCI.

Conus branch artery utilization in percutaneous coronary intervention for chronic total occlusion

Data on the prevalence of conus branch artery (CBA) is scarce, and its utilization in percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) is non-existing. The present study examined carefully in a large cohort the angiographic prevalence of CBA, its role as a collateral channel for the occlusion, and the potential usage of CBA in contemporary CTO PCI. We retrospectively examined consecutive CTO PCIs from our database between 2016 and 2019. All CTO PCIs were evaluated and the results with complications were recorded to determine the prevalence and utilization of CBA. From January 2016 to December 2019, a total of 556 CTO PCI attempts in 546 patients by high-volume operators were enrolled. The clinical, angiographic, and procedural details were collected. CBA was identifiable in 85.3% of these patients, and CBA providing visible collaterals connected to CTO distal lumen was found in 27.8% of patients. 84 CBA were used for balloon anchoring, 17 for selective distal true lumen visualization, and 9 as actual retrograde interventional collateral channel during CTO PCI. Only 1 patient suffered from chest pain during CBA balloon anchoring, and no other procedural complication such as arrhythmia or perforation occurred.CBA is frequently seen in coronary CTO. Its existence provided potential for various CTO PCI technique applications, without increase in risk.

The Role of Multimodality Imaging for Percutaneous Coronary Intervention in Patients With Chronic Total Occlusions

Background

Percutaneous coronary intervention (PCI) of Chronic total occlusions (CTOs) has been traditionally considered a challenging procedure, with a lower success rate and a higher incidence of complications compared to non-CTO-PCI. An accurate and comprehensive evaluation of potential candidates for CTO-PCI is of great importance. Indeed, assessment of myocardial viability, left ventricular function, individual risk profile and coronary lesion complexity as well as detection of inducible ischemia are key information that should be integrated for a shared treatment decision and interventional strategy planning. In this regard, multimodality imaging can provide combined data that can be very useful for the decision-making algorithm and for planning percutaneous CTO recanalization.

Aims

The purpose of this article is to appraise the value and limitations of several non-invasive imaging tools to provide relevant information about the anatomical characteristics and functional impact of CTOs that may be useful for the pre-procedural assessment and follow-up of candidates for CTO-PCI. They include echocardiography, coronary computed tomography angiography (CCTA), nuclear imaging, and cardiac magnetic resonance (CMR). As an example, CCTA can accurately delineate CTO location and length, distal coronary bed, vessel tortuosity and calcifications that can predict PCI success, whereas stress CMR, nuclear imaging and stress-CT can provide functional evaluation in terms of myocardial ischemia and viability and perfusion defect extension.

Chronic Total Occlusion Percutaneous Coronary Intervention in Patients With Prior Coronary Artery Bypass Graft: Current Evidence and Future Perspectives

Coronary chronic total occlusion (CTO), which occurs in 18. 4-52% of all patients referred for coronary angiography, represents one of the last barriers in coronary intervention. Approximately half of all patients with prior coronary artery bypass graft (CABG), who undergo coronary angiography, are diagnosed with coronary CTO. In fact, these patients often develop recurrent symptoms and events, necessitating revascularization. Currently, there is neither a consensus nor developed guidelines for the treatment of CTO patients with prior CABG, and the prognosis of these patients remains unknown. In this review, we discuss current evidence and future perspectives on CTO revascularization in patients with prior CABG, with special emphasis on clinical and lesion characteristics, procedural success rates, periprocedural complications, and long-term outcomes.

Predictors of angina resolution after percutaneous coronary intervention in stable coronary artery disease

BACKGROUND

Elective percutaneous coronary intervention (PCI) is performed to relieve symptoms of angina. Identifying patients who will benefit symptomatically after PCI would be clinically advantageous but robust predictors of symptom resolution are ill-defined.

METHODS

Prospective indexing of baseline angina status, clinical, and procedural characteristics were collected over a 5-year period in a regional revascularization registry. At 1-year follow-up, angina resolution was assessed. We performed a stepwise selection algorithm to identify predictors of persistent angina at 1 year.

RESULTS

A total of 777 patients were included in the analysis and the median follow-up was 387 days. Mean age of the cohort was 66.6 years, 23.8% were female and 23.3% had baseline Canadian Cardiovascular Society class 3 or 4 angina. Overall, 13.1% had persistent angina. The only predictor of persistent angina was the presence of a residual chronic total occlusion after PCI with odds ratio of 3.06 (95% confidence interval, 1.81-5.17). Residual stenoses 50-69%, 70-89%, and 90-99% were not associated with residual angina after PCI.

CONCLUSION

Most patients achieved symptom resolution with PCI and optimal medical therapy. A residual chronic total occlusion after PCI was associated with persistent angina. Other degrees of stenoses were not associated with persistent angina.