Effectiveness of recanalization of chronic total occlusions: A systematic review and meta-analysis

doi:10.1016/j.ahj.2010.04.015

American Heart Journal

Volume 160, Issue 1, July 2010, Pages 179-187

https://doi.org/10.1016/j.ahj.2010.04.015 Get rights and content

Background

Chronic total occlusion (CTO) recanalizations remain extremely challenging procedures. With improvements in technology and techniques, success rates for recanalization of CTO continue to improve. However, the clinical benefits of this practice remain unclear. The aim of the study was to determine the effectiveness of CTO recanalization on clinical outcomes.

Methods

We performed a systematic review and meta-analysis of published studies comparing CTO recanalization to medical management. Data were extracted in duplicate and analyzed by a random effects model.

Results

We did not identify any randomized controlled trials or observational studies comparing CTO recanalization to a planned medical management. We did identify 13 observational studies comparing outcomes after successful vs failed CTO recanalization attempt. These studies encompassed 7,288 patients observed over a weighted average follow-up of 6 years. There were 721 (14.3%) deaths of 5,056 patients after successful CTO recanalization compared to 390 deaths (17.5%) of 2,232 patients after failed CTO recanalization (odds ratio [OR] 0.56, 95% CI 0.43-0.72). Successful recanalization was associated with a significant reduction in subsequent coronary artery bypass graft surgery (CABG) (OR 0.22, 95% CI 0.17-0.27) but not in myocardial infarction (OR 0.74, 95% CI 0.44-1.25) or major adverse cardiac events (OR 0.81, 95% CI 0.55-1.21). In the 6 studies that reported angina status, successful recanalization was associated with a significant reduction in residual/recurrent angina (OR 0.45, 95% CI 0.30-0.67).

Conclusions

In highly selected patients considered for CTO recanalization, successful attempts appear to be associated with an improvement in mortality and with a reduction for the need for CABG as compared to failed recanalization. However, given the observational nature of the reviewed evidence, randomized clinical trials are needed to confirm these findings.

Section snippets

Methods

We performed a systematic review and meta-analysis in accordance with the standards set forth by the Quality of Reporting of Meta-analyses (QUOROM) statement.⁵ We searched PubMed, EMBASE, Web of Science, and the Cochrane Library (up to January 30, 2009). We used the following keywords: “chronic total occlusion,” “percutaneous coronary intervention,” “angioplasty,” and “stent.” We limited our search to the English and French language. In addition, we hand-searched references of retrieved

Results

We did not identify any randomized controlled trial (RCT) or observational study comparing CTO recanalization to a planned medical management strategy. We identified 13 observational studies comparing successful CTO recanalization to a strategy of medical management as a result of attempted but failed CTO recanalization.6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18Figure 1 shows the flow diagram leading to our article selection. Included studies encompassed 7,288 patients treated between 1979

Discussion

Despite increasing interest in the use of PCI for CTO, we found no randomized or observational studies directly comparing recanalization to medical management. Therefore, the current meta-analysis applies only to clinical outcomes after attempted recanalization. In this selected population, we found that successful CTO recanalization was associated with a 44% reduction in mortality, a 78% reduction in subsequent CABG, and a 55% reduction in residual/recurrent angina. Successful recanalization

Conclusion

In the highly selected population of patients who underwent successful recanalization of a CTO, long-term outcomes appear to be improved. Our findings support the evidence suggesting a survival advantage associated with successful versus failed attempt of CTO recanalization as far as it is possible short of an RCT. However, based on the observational nature of the evidence, randomized control trials comparing recanalization to a planed medical management are needed to confirm these findings.

Acknowledgement

Dr Rinfret is a junior clinician-scientist supported by the Fonds de recherche en santé du Québec (FRSQ).

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Cited by (351)

Long-Term Outcomes in Patients With Chronic Total Occlusion
2024, American Journal of Cardiology
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.
Chronic total occlusion rotational atherectomy (CTO RA) versus non-CTO RA in coronary artery disease: A meta-analysis of clinical outcomes and complications
2023, American Heart Journal Plus: Cardiology Research and Practice
Chronic total occlusion rotational atherectomy (CTO RA) is an emerging intervention in coronary artery disease (CAD), although data comparing its outcomes and complications with non-CTO RA are scarce. We sought to evaluate the outcomes of RA in CTO lesions compared to those in non-CTO lesions by performing a meta-analysis.
We conducted a systematic review and meta-analysis of studies comparing the clinical outcomes and complications between CTO RA and non-CTO RA in patients with CAD. We searched PUBMED, CINAHL, EMBASE and Cochrane Central Register of Clinical Trials for any studies that compared the outcomes of RA in CTO and non-CTO lesions. The outcomes analyzed included in-hospital major adverse cardiovascular events (MACE), target vessel revascularization (TVR), angiographic success, procedural success, periprocedural complications, coronary perforation, and all-cause mortality.
Four studies with a total of 1868 patients were included, spanning from 2018 to 2022, from Germany, Taiwan, and Korea. The median age of included patients was 71. The rate of the pooled results indicated a moderate, non-significant increase in in-hospital MACE and TVR for CTO RA compared to non-CTO RA. There was a small, non-significant decrease in angiographic and procedural success in CTO RA compared to non-CTO RA. CTO RA was associated with a non-significant increase in periprocedural complications and a significant increase in coronary perforation compared to non-CTO RA. All-cause mortality showed a non-significant increase in the CTO RA group.
This meta-analysis provides evidence that while CTO RA may be associated with a higher risk of coronary perforation, the risk of other outcomes including MACE, TVR, and all-cause mortality is not significantly different compared to non-CTO RA. More research is needed to further understand these relationships and to optimize treatment strategies in patients with CAD undergoing CTO RA.
Gender-Based Differences in Outcomes After Percutaneous Coronary Intervention of Chronic Total Occlusions (Insights from a Large Single-Center Registry)
2023, American Journal of Cardiology
Patients who undergo percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) are at a high risk for both periprocedural and post-procedural adverse events. Whether gender-differences in outcomes exist after PCI of CTO remain unclear. Therefore, we sought to investigate gender-based differences in outcomes after CTO-PCI. All patients who underwent elective CTO intervention from January 2012 to December 2017 at The Mount Sinai Hospital (New York, New York) were included. The primary end point of interest was major adverse cardiac events defined as the composite of death, myocardial infarction, and target vessel revascularization at 1 year of follow-up. A total 1,897 patients were included, of which 368 were women (19.4%). Mean follow-up time was 174 days. Women were older (66.8 ± 11.3 years vs 62.6 ± 10.9 years) and had a higher prevalence of co-morbidities including diabetes and chronic kidney disease. There were no significant differences in the rate of successful CTO-PCI between groups (73.5% vs 73.2%, p = 0.91). Women had higher rates of procedure-related complications including increased risk of post-procedural bleeding (4.1% vs 1.8%, p = 0.009) and acute vessel closure (1.36% vs 0.2%, p = 0.009). In multivariable-adjusted analysis, female gender was associated with higher risk of major adverse cardiac event and target vessel revascularization at 1 year. In conclusion, in this large single-center study, women who underwent percutaneous CTO revascularization experienced higher rates of periprocedural complications and worse clinical outcomes at 1 year compared with men. Further research is needed to address disparities in gender-specific outcomes of CTO-PCI.
Short- and Long-term Outcomes of Percutaneous Coronary Interventions in Chronic and Non-chronic Total Occlusions: A Meta-analysis of 690,123 Patients
2023, Current Problems in Cardiology
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.
Long-Term Outcomes of Chronic Total Occlusion Percutaneous Coronary Intervention Among Medicare Beneficiaries
2023, Journal of the Society for Cardiovascular Angiography and Interventions
Chronic total occlusion (CTO) percutaneous coronary interventions (PCIs) represent 4% of all PCIs for stable angina in the United States and have been associated with lower success and higher in-hospital event rates compared with non-CTO PCIs. We aimed to examine long-term outcomes of CTO PCI compared with non-CTO PCI, including prespecified subgroups of high-risk non-CTO PCI (atherectomy/saphenous vein graft/unprotected left main).
Among 551,722 patients in the National Cardiovascular Data Registry CathPCI Registry linked to Medicare (July 2009-December 2016), we evaluated in-hospital events and long-term major adverse cardiovascular events of CTO PCIs (N = 29,407) compared with non-CTO PCIs (N = 522,315). We then evaluated similar outcomes between CTO PCIs and high-risk non-CTO PCIs (N = 53,662). We excluded patients with ST-elevation myocardial infarction and non–ST-elevation myocardial infarction.
Patients undergoing CTO PCI were more likely to be younger and male. CTO PCI was associated with a higher risk of in-hospital events compared with non-CTO PCI (7.0% vs 4.2%; P < .001) and high-risk non-CTO PCI (7.0% vs 6.5%; P = .008). In addition, CTO PCI was associated with a slightly higher risk of long-term repeat revascularization compared with non-CTO PCI (adjusted hazard ratio [aHR], 1.09; 95% CI, 1.05-1.13). However, compared with high-risk non-CTO PCIs, CTO PCIs were associated with a slightly lower risk of long-term major adverse cardiovascular events (aHR, 0.87; 95% CI, 0.84-0.90) and readmission (aHR, 0.87; 95% CI, 0.84-0.90).
In this study, CTO PCI was associated with higher risk of both in-hospital and out-of-hospital events but a slightly lower risk of long-term events compared with high-risk non-CTO PCIs. These findings shed light on the complexity of various PCI procedures that can inform clinicians and patients of expected outcomes.
Why and How Should We Treat Chronic Total Occlusion? Evolution of State-of-the-Art Methods and Future Directions
2022, Canadian Journal of Cardiology
Citation Excerpt :
In the large OPEN-CTO (Outcomes, Patient Health Status, and Efficiency in Chronic Total Occlusion Hybrid Procedures) registry, 72% of patients underwent CTO PCI for symptom relief, and 11% for ischemia reduction.6 In observational studies that compared outcomes after successful vs failed CTO PCI, patients who had their CTO opened had a 62% reduction in the risk of subsequent angina.12,13 CTO PCI is also associated with substantial improvement in several aspects of quality of life (QOL), including better physical functioning, less angina frequency, and overall QOL as assessed with the Seattle-Angina Questionnaire (SAQ), in the short and long terms.6,14
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.
L’occlusion totale chronique est considérée comme la lésion coronarienne la plus complexe en cardiologie interventionnelle. L’absence de lumière visible à l’angiographie rend difficile la détermination du trajet du vaisseau touché et empêche le passage d’un fil par les techniques classiques. Source fréquente d’ischémie grave, l’occlusion chronique constitue aussi un marqueur d’athérosclérose avancée, qui comporte elle aussi des caractéristiques complexes, notamment des lésions étendues, des bifurcations, de la calcification, un remodelage défavorable des vaisseaux sanguins, une atteinte distale et une déformation anatomique due à des anciens pontages. L’athérosclérose avancée est par ailleurs souvent associée à d’autres troubles, par exemple une dysfonction du ventricule gauche, un pontage coronarien ou une atteinte pluritronculaire, qui augmentent la difficulté et les risques associés aux interventions. De nouvelles techniques et des technologies spécialisées ont été mises au point pour tenir compte de ces particularités. Lorsqu’elles sont employées chez les bons candidats, elles permettent d’améliorer le taux de réussite et la sécurité des interventions, ainsi que les résultats pour les patients. Nous tentons ici d’offrir aux cardiologues généralistes un survol de ces avancées, afin de les aider à conseiller leurs patients chez qui une revascularisation est envisagée.

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Clinical InvestigationInterventional CardiologyEffectiveness of recanalization of chronic total occlusions: A systematic review and meta-analysis

Background

Methods

Results

Conclusions

Section snippets

Methods

Results

Discussion

Conclusion

Acknowledgement

Percutaneous recanalization of chronically occluded coronary arteries: a consensus document: part I

Circulation

Percutaneous recanalization of chronically occluded coronary arteries: a consensus document: part II

Circulation

Retrograde percutaneous recanalization of chronic total occlusion of the coronary arteries: procedural outcomes and predictors of success in contemporary practice

Circ Cardiovasc Interv

Retrograde techniques and the impact of operator volume on percutaneous intervention for coronary chronic total occlusions an early U.S. experience

JACC Cardiovasc Interv

Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement. Quality of Reporting of Meta-analyses

Lancet

Percutaneous coronary intervention for chronic total occlusions: the Thoraxcenter experience 1992-2002

Eur Heart J

Procedural outcomes and long-term survival among patients undergoing percutaneous coronary intervention of a chronic total occlusion in native coronary arteries: a 20-year experience

J Am Coll Cardiol

Percutaneous transluminal coronary angioplasty of chronic total occlusions. Primary success, restenosis, and long-term clinical follow-up

Circulation

Immediate results and one-year clinical outcome after percutaneous coronary interventions in chronic total occlusions: data from a multicenter, prospective, observational study (TOAST-GISE)

J Am Coll Cardiol

Percutaneous transluminal coronary angioplasty of chronic total occlusions. Determinants of primary success and long-term clinical outcome

Catheter Cardiovasc Interv

Trends in outcomes after percutaneous coronary intervention for chronic total occlusions: a 25-year experience from the Mayo Clinic

J Am Coll Cardiol

Long-term results of successful and failed angioplasty for chronic total coronary arterial occlusion

Am J Cardiol

Impact of complete revascularization with percutaneous coronary intervention on survival in patients with at least one chronic total occlusion

Eur Heart J

Percutaneous angioplasty of chronically occluded coronary arteries: long-term clinical follow-up

Kardiol Pol

Coronary angioplasty for chronic total occlusion reduces the need for subsequent coronary bypass surgery

Am Heart J

Is percutaneous transluminal coronary angioplasty in chronic total coronary occlusion justified? Long term results in a series of 201 patients

Arch Mal Coeur Vaiss

Percutaneous coronary intervention for chronic total occlusions: improved survival for patients with successful revascularization compared to a failed procedure

Catheter Cardiovasc Interv

Clinical Investigation
Interventional Cardiology
Effectiveness of recanalization of chronic total occlusions: A systematic review and meta-analysis