Successful recanalization of chronic total occlusions is associated with improved long-term survival.

This study investigated the impact of procedural success on mortality following chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in a large cohort of patients in the drug-eluting stent era. Despite advances in expertise and technologies, many patients with CTO are not offered PCI. A total of 6,996 patients underwent elective PCI for stable angina at a single center (2003 to 2010), 836 (11.9%) for CTO. All-cause mortality was obtained to 5 years (median: 3.8 years; interquartile range: 2.0 to 5.4 years) and stratified according to successful chronic total occlusion (sCTO) or unsuccessful chronic total occlusion (uCTO) recanalization. Major adverse cardiac events (MACE) included myocardial infarction (MI), urgent revascularization, stroke, or death. A total of 582 (69.6%) procedures were successful. Stents were implanted in 97.0% of successful procedures (mean: 2.3 ± 0.1 stents per patient, 73% drug-eluting). Prior revascularization was more frequent among uCTO patients: coronary artery bypass grafting (CABG) (16.5% vs. 7.4%; p < 0.0001), PCI (36.0% vs. 21.2%; p < 0.0001). Baseline characteristics were otherwise similar. Intraprocedural complications, including coronary dissection, were more frequent in unsuccessful cases (20.5% vs. 4.9%; p < 0.0001), but did not affect in-hospital MACE (3% vs. 2.1%; p = NS). All-cause mortality was 17.2% for uCTO and 4.5% for sCTO at 5 years (p < 0.0001). The need for CABG was reduced following sCTO (3.1% vs. 22.1%; p < 0.0001). Multivariate analysis demonstrated that procedural success was independently predictive of mortality (hazard ratio [HR]: 0.32 [95% confidence interval (CI): 0.18 to 0.58]), which persisted when incorporating a propensity score (HR: 0.28 [95% CI: 0.15 to 0.52]). Successful CTO PCI is associated with improved survival out to 5 years. Adoption of techniques and technologies to improve procedural success may have an impact on prognosis.

Jones DA ，Weerackody R ，Rathod K ，Behar J ，Gallagher S ，Knight CJ ，Kapur A ，Jain AK ，Rothman MT ，Thompson CA ，Mathur A ，Wragg A ，Smith EJ ... -  《-》

Long-term clinical outcomes of successful versus unsuccessful revascularization with drug-eluting stents for true chronic total occlusion.

The aims of this study were to investigate the long-term clinical outcomes of patients with successful versus unsuccessful revascularization with drug-eluting stents (DES) for chronic total occlusion (CTO). The benefits of successful revascularization of CTO remain unclear. Consecutive patients (n = 333) with "true" CTO, defined as Thrombolysis In Myocardial Infarction (TIMI) flow grade 0 on angiography and duration ≥3 months, were divided into two groups, those with successful (CTO success group, n = 251) and unsuccessful (CTO failure group, n = 82) revascularization with DES for CTO lesions. The primary endpoint was defined as major adverse cardiac events (MACE) the composite of death, Q-wave myocardial infarction (MI), or target vessel revascularization (TVR). The CTO success group was significantly younger, with a higher involvement of LAD, and lower incidences of renal failure, previous myocardial infarction, and previous coronary intervention than the CTO failure group. After a median follow up of 1,317 days (interquartile range, 1,059-1,590 days), there were no significant between-group differences in rate of MACE, both after crude analysis (9.4% vs. 11.8%, log-rank P = 0.16) and after adjustment (HR 1.17; 95% CI 0.47-2.88, P = 0.53). On multivariate analysis, major predictors of MACE were left ventricle ejection fraction (LVEF) <40% (HR 3.14; 95% CI 1.39-7.09, P = 0.005) and multiple CTO (HR 2.38; 95% CI 1.01-5.71, P = 0.049). Long-term clinical outcomes were similar in the CTO success and failure groups. Multiple CTOs and LVEF <40% in CTO patients were independent predictors of MACE.

Lee SW ，Lee JY ，Park DW ，Kim YH ，Yun SC ，Kim WJ ，Suh J ，Cho YH ，Lee NH ，Kang SJ ，Lee CW ，Park SW ，Park SJ ... -  《-》

Successful versus unsuccessful antegrade recanalization of single chronic coronary occlusion: eight-year experience and outcomes by a propensity score ascertainment.

The effectiveness of revascularization of chronic total occlusion (CTO) remains intriguing. Thus, we sought to investigate whether a successful PCI for single CTO improves outcomes in a setting of stable angina and chronic occlusion of single coronary artery. Of 11 957 consecutive patients referred for nonurgent PCI between 2003 and 2010, 1110 displayed single CTO and were enrolled to the central CTO-registry database. The primary end-point included all-cause mortality, the secondary end-point a composite of safety outcome measure of all-cause death, nonfatal-MI, the need for urgent revascularization and stroke. The major adverse cardiovascular event (MACE) records were extracted from the national administrative database and all patients were linked to the long-term follow-up. Since the patient assignment was not random, we performed the propensity scoring to minimize selection bias; 734 patients (66%) had a successful PCI-CTO. Compared with successful procedures, unsuccessful procedures had similar rates of all-cause death both in crude (HR, 0.78; 95%CI, 0.49-1.25; P = 0.30) and adjusted analysis (HR, 0.80; 95%CI, 0.50-1.28; P = 0.34). A similar, significant reduction in overall MACE was noted with successful PCI-CTO compared with unsuccessful procedure in unadjusted (HR, 0.74; 95%CI, 0.56-0.96; P = 0.020) and adjusted calculation (HR, 0.73; 95%CI, 0.56-0.96; P = 0.019). Patients after successful PCI-CTO as compared with failed recanalization less frequently underwent surgical revascularization. The benefit was sustained at 3 years follow-up. Successful PCI for single CTO does not improve long-term survival, nonetheless, is associated with reduced overall MACE and the need for surgical revascularization.

Jaguszewski M ，Ciecwierz D ，Gilis-Malinowska N ，Fijalkowski M ，Targonski R ，Masiewicz E ，Strozyk A ，Duda M ，Chmielecki M ，Lewicki L ，Dubaniewicz W ，Burakowski S ，Drewla P ，Skarzynski P ，Rynkiewicz A ，Alibegovic J ，Landmesser U ，Gruchala M ... -  《-》

Long-term outcome of percutaneous coronary intervention for chronic total occlusions.

The aim of this study was to evaluate long-term clinical outcomes after percutaneous coronary intervention (PCI) for chronic total occlusions (CTO). Despite technical advancements, there is a paucity of data on long-term outcomes after PCI of CTO. We evaluated long-term clinical outcomes in 1,791 patients who underwent PCI of 1,852 CTO at 3 tertiary care centers in the United States, South Korea, and Italy between 1998 and 2007. Median follow-up was 2.9 years (interquartile range: 1.5 to 4.6 years). Procedural success was obtained in 1,226 (68%) patients. Stents were implanted in 1,160 patients (95%); 396 patients (34%) received bare-metal stents (BMS), and 764 patients (66%) received drug-eluting stents (DES). After multivariable analysis, successful CTO PCI was an independent predictor of a lower cardiac mortality (hazard ratio [HR]: 0.40, 95% confidence interval [CI]: 0.21 to 0.75, p < 0.01) and reduced need for coronary artery bypass graft surgery (HR: 0.21, 95% CI: 0.13 to 0.40, p < 0.01); it also correlated with a strong trend toward lower all-cause mortality (HR: 0.63, 95% CI: 0.40 to 1.00, p = 0.05) at 5-year follow-up. Among patients who underwent stent implantation, treatment with DES rather than BMS resulted in less target vessel revascularization at long-term follow-up (17.2% vs. 31.1%, p < 0.01); definite/probable stent thrombosis rates were similar (DES 1.7%, BMS 2.3%, p = 0.58). Within the DES subgroup, patients treated with paclitaxel-eluting stents and sirolimus-eluting stents had similar clinical outcomes. Successful CTO PCI is associated with reduced long-term cardiac mortality and need for coronary artery bypass graft surgery. Treatment of CTO with DES rather than BMS is associated with a significant reduction in target vessel revascularization with similar rates of stent thrombosis. Paclitaxel-eluting stents and sirolimus-eluting stents had similar long-term safety and efficacy outcomes.

Mehran R ，Claessen BE ，Godino C ，Dangas GD ，Obunai K ，Kanwal S ，Carlino M ，Henriques JP ，Di Mario C ，Kim YH ，Park SJ ，Stone GW ，Leon MB ，Moses JW ，Colombo A ，Multinational Chronic Total Occlusion Registry ... -  《-》

Survival after percutaneous coronary intervention for chronic total occlusion.

Toma A ，Gick M ，Minners J ，Ferenc M ，Valina C ，Löffelhardt N ，Gebhard C ，Riede F ，Neumann FJ ，Buettner HJ ... -  《-》