CTO Contraversies

CTO PCI has been done extensively with great cost and high risk to the patient. This time consuming and costly procedure was justified based on non-randomized poorly conducted retrospective studies of successful PCI vs non-successful PCI in CTO patients. These studies were poorly adjusted, and complications of PCI were counted as medical therapy outcome during unsuccessful PCI. Recently many randomized studies were published showing lack of benefit of CTO PCI. One published in Cardiovascular Revascular Med. 2016 Feb 18. Looking at Long-term clinical outcomes after successful and failed recanalization to native chronic Total occlusion: Insights from the Busan chronic Total occlusion (B-CTO) Registry looked at first-time PCI that was performed in 438 consecutive patients with 473 target CTO lesions. Patients after procedural success (n=355; 378 CTO lesions) and failure (n=83; 95 CTO lesions) were followed for an average 40 months. The incidence of MACE did not differ {6% vs.3.1%, HR=0.47; CI [0.16-1.35; p=0.162. It was concluded that risks of MACE after PCI-CTO over long-term follow-up were minimal, and do not depend on the procedure success. First large randomized trial was Decision CTO trial. The goal of the trial was to assess the safety and efficacy of chronic total occlusion CTO PCI compared with optimal medical therapy. Patients were randomized to CTO-PCI + OMT (n = 417) or OMT (n = 398). The trial had to be stopped early due to slow enrollment. In the PCI arm, revascularization for all significant non-CTO lesions within a vessel diameter of ≥2.5 mm. PCI had to be completed within 30 days of randomization. All patients were prescribed guideline-derived OMT. Total number of enrollees: 834. Duration of follow-up: 5 months. Enrollment criterion: Silent ischemia, stable angina, or acute coronary syndrome. Principal Findings: The primary endpoint for CTO-PCI + OMT vs. OMT, major adverse cardiac events (MACE) at 3 years (all-cause mortality, MI, stroke, repeat revascularization), was 20.6% vs. 19.6%not different. MACE at 5 years: 26.3% vs. 25.1%, p = 0.67. Quality of life measures, including Seattle Angina Questionnaire for angina was also similar. The results of this trial indicate that routine CTO-PCI + OMT is not superior to OMT alone in reducing cardiovascular outcomes. Another Randomized Multicenter Trial to Evaluate the Utilization of Revascularization or Optimal Medical Therapy for the Treatment of Chronic Total Coronary Occlusions (EUROCTO-Trial) showed also no benefit in hard outcome such as death. Finally a recent meta-analysis of randomized CTO trial showed no benefit of CTO intervention. (...)