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 ... -  《-》

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 ... -  《-》

Successful Recanalization of Native Coronary Chronic Total Occlusion Is Not Associated With Improved Long-Term Survival.

The purpose of this study was to evaluate long-term clinical outcomes after drug-eluting stent-supported percutaneous coronary intervention (PCI) for native coronary total occlusion (CTO). The benefit of successful recanalization of CTO on prognosis remains uncertain. Between March 2003 and May 2014, 1,173 consecutive patients with CTO of native coronary vessels requiring PCI were enrolled. Drug-eluting stent implantation was performed in all successful procedures (1,004 patients, 85.6%). During a median follow-up of 4.6 years, the adjusted risks of all-cause mortality (hazard ratio [HR]: 1.04; 95% confidence interval [CI]: 0.53 to 2.04; p = 0.92) and the composite of death or myocardial infarction (HR: 1.05; 95% CI: 0.56 to 1.94; p = 0.89) were found to be comparable between patients with successful and failed CTO-PCI, whereas the adjusted risk of target vessel revascularization (HR: 0.15; 95% CI: 0.10 to 0.25; p < 0.001) and coronary artery bypass grafting (HR: 0.02; 95% CI: 0.006 to 0.06, p < 0.001) was significantly higher in patients with failed CTO-PCI. Among patients (n = 879) in whom complete revascularization for non-CTO vessels was performed, the risk of death or the composite of death or myocardial infarction were not found to differ between patients who underwent successful recanalization of the remaining CTO and patients who did not. This finding was consistent regardless of whether the patient had a multivessel disease including CTO or only had a single CTO disease. Successful CTO-PCI compared with failed PCI was not associated with a lesser risk for mortality. However, successful CTO-PCI was associated with significantly less subsequent coronary artery bypass grafting.

Lee PH ，Lee SW ，Park HS ，Kang SH ，Bae BJ ，Chang M ，Roh JH ，Yoon SH ，Ahn JM ，Park DW ，Kang SJ ，Kim YH ，Lee CW ，Park SW ，Park SJ ... -  《-》

Long-term clinical outcomes after successful and failed recanalization to native chronic Total occlusion: Insights from the Busan chronic Total occlusion (B-CTO) Registry.

To assess hard major adverse clinical events (HMACE) after successful versus failed percutaneous coronary intervention for chronic total occlusion (PCI-CTO). There are limited data regarding long-term HMACE risks based on PCI-CTO success. First-time PCI 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 40months (7-77months range). We compared HMACE (composite of cardiac death, non-fatal myocardial infarction (MI), and stroke) dependent on the success of PCI. The incidence of HMACE was low, with a total of 16 events, and did not differ {6% vs.3.1%, HR=0.47; CI [0.16-1.35; p=0.162} dependent on the success of PCI-CTO. There were less cardiac deaths {0.3% vs. 1.2%, RR=0.22; CI [0.01-3.50];p=0.283}, non fatal MI {1.1% vs.3.6%, RR=0.27; CI [0.06-1.22], p=0.089}, but more strokes {1.7% vs.1.2%, RR=1.32; CI [0.16-10.99], p=0.795} after successful PCI-CTO. The risks of HMACE after PCI-CTO over long-term follow-up were minimal, and do not depend on the procedure success. This unexpected finding somewhat challenge the aggressive interventional approach, and should be confirmed in the adequately powered randomized trial.

Kim MH ，Mitsudo K ，Jin CD ，Kim TH ，Cho YR ，Park JS ，Park K ，Park TH ，Serebruany V ... -  《-》

Long-term clinical outcomes after percutaneous coronary intervention for chronic total occlusions in elderly patients (≥75 years): five-year outcomes from a 1,791 patient multi-national registry.

To investigate procedural success rates and long-term clinical outcome of percutaneous coronary intervention (PCI) for chronic total occlusions (CTO) in elderly patients. Little is known about procedural success and long-term clinical outcome of PCI for CTO in the elderly. A total of 1,791 consecutive patients with 1,852 CTO underwent PCI at three large centers in USA, Italy, and South Korea. Outcomes included procedural success and major adverse cardiac events (MACE, composite of mortality, myocardial infarction, or coronary artery bypass graft surgery [CABG]).Time-to-event analyses were performed using Kaplan-Meier statistics, and the log-rank statistic was used to test for differences between patients aged ≥75 and patients aged <75 years. Two hundred and thirteen patients (12%) were aged ≥75 years. Procedural success rates were similar in elderly patients compared with patients <75 years (63.8% vs. 69.1%, P = 0.12). Median follow-up was 890 days (IQR: 380-1,480 days). MACE rates after successful versus failed PCI were 25.8% versus 42.3% in the elderly (P = 0.02) and 11.2 versus 20.8% in younger patients (P < 0.01). In elderly patients, this reduction in MACE after successful PCI was mainly driven by a reduction in CABG (0.0% vs. 20.4%, P < 0.01), there were no significant differences in terms of mortality (19.6% vs. 24.6%, P = 0.13) or MI (11.5% vs. 8.0%, P = 0.87). CTO PCI in patients ≥75 years has similar success as in patients <75 years. In elderly patients undergoing CTO PCI, MACE rates were relatively high but successful revascularization is associated with a reduction in MACE at 5-year follow-up in both elderly and younger patients.

Hoebers LP ，Claessen BE ，Dangas GD ，Park SJ ，Colombo A ，Moses JW ，Henriques JP ，Stone GW ，Leon MB ，Mehran R ，Multinational CTO Registry ... -  《-》