Meta-Analysis of Effect on Mortality of Percutaneous Recanalization of Coronary Chronic Total Occlusions Using a Stent-Based Strategy

doi:10.1016/j.amjcard.2012.10.034

The American Journal of Cardiology

Volume 111, Issue 4, 15 February 2013, Pages 521-525

https://doi.org/10.1016/j.amjcard.2012.10.034 Get rights and content

We performed a systematic review and meta-analysis comparing the all-cause mortality outcomes of successful percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs) with unsuccessful CTO-PCI, using a stent-based strategy. Multiple studies comparing successful CTO-PCI with unsuccessful CTO-PCI have reported variable outcomes. No systematic review or meta-analysis has been performed after stenting became the default strategy for CTO-PCI. Searching major electronic databases, 64 studies were identified using the keywords “CTO,” “PCI,” and “mortality.” Using the Preferred Reporting Items for Systematic Reviews and Meta-analyses method, 13 studies met the criteria for inclusion in the present meta-analysis. The short-term (≤30 days) and long-term (≥1 year) mortality outcomes were analyzed comparing successful CTO-PCI and unsuccessful CTO-PCI. Coronary perforation and its association with CTO-PCI success was analyzed. A significant reduction in short-term mortality was noted with successful CTO-PCI compared to unsuccessful CTO-PCI (odds ratio 0.218, 95% confidence interval 0.095 to 0.498, Z = −3.61, p <0.001). A similar, significant reduction in long-term mortality was noted with successful CTO-PCI compared to unsuccessful CTO-PCI (odds ratio 0.391, 95% confidence interval 0.311 to 0.493, Z = −7.957, p <0.001). A significant association was present between coronary perforation and unsuccessful CTO-PCI (odds ratio 0.168, 95% confidence interval 0.104 to 0.271, Z = −7.333, p <0.001). In conclusion, successful CTO-PCI using a predominantly stent-based strategy is associated with a significant reduction in short- and long-term mortality compared to unsuccessful CTO-PCI. Coronary perforation was associated with CTO-PCI failure.

Section snippets

Methods

Our meta-analysis followed the method outlined in the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement.⁴ We searched the indexed studies using major databases, including PubMed, the Cochrane Library, and Google Scholar. The keywords included “chronic total occlusion,” “percutaneous coronary intervention,” and “outcomes.” Abstracts from major interventional cardiology meetings were searched using the same keywords.

The titles and abstracts of 64 relevant

Results

The search resulted in 64 studies. Of the 13 studies included in the present analysis, 65, 6, 7, 8, 9, 10 had reported the mortality outcomes at ≤30 days of follow-up, and 12 studies5, 6, 7, 8, 9, 11, 12, 13, 14, 15, 16, 17 had reported the mortality outcomes at ≥1 year of follow-up for patients with successful versus unsuccessful CTO-PCI. Of the 13 studies, 6 studies8, 9, 11, 13, 14, 17 were prospective and 7 studies5, 6, 7, 10, 12, 15, 16 were retrospective. The studies reported by Suero et al

Discussion

CTOs are encountered in approximately 20% of patients referred for coronary angiography²² and have been associated with worse long-term outcomes.23, 24 The advent of better equipment, including tapered-tipped guidewires,²⁵ hydrophilically coated specialty microcatheters, and dedicated devices,²⁶ and a better understanding of the substrate and increasing operator experience has led to an improvement in the antegrade CTO-PCI success rates. Increasing adoption of the retrograde technique²⁷ has

Disclosures

The authors have no conflicts of interest to disclose.

References (30)

D. Joyal et al.
Effectiveness of recanalization of chronic total occlusions: a systematic review and meta-analysis
Am Heart J
(2010)
P. Rubartelli et al.
Coronary stent implantation is superior to balloon angioplasty for chronic coronary occlusions: six-year clinical follow-up of the GISSOC trial
J Am Coll Cardiol
(2003)
D.A. Jones et al.
Successful recanalization of chronic total occlusions is associated with improved long-term survival
JACC Cardiovasc Interv
(2012)
S. Rathore et al.
Procedural and in-hospital outcomes after percutaneous coronary intervention for chronic total occlusions of coronary arteries 2002 to 2008: impact of novel guidewire techniques
JACC Cardiovasc Interv
(2009)
A. de Labriolle et al.
Comparison of safety, efficacy, and outcome of successful versus unsuccessful percutaneous coronary intervention in “true” chronic total occlusions
Am J Cardiol
(2008)
Z. Olivari et al.
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
(2003)
R. Mehran et al.
Long-term outcome of percutaneous coronary intervention for chronic total occlusions
JACC Cardiovasc Interv
(2011)
J.A. Suero et al.
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
(2001)
D.M. Safley et al.
Improvement in survival following successful percutaneous coronary intervention of coronary chronic total occlusions: variability by target vessel
JACC Cardiovasc Interv
(2008)
A. Prasad et al.
Trends in outcomes after percutaneous coronary intervention for chronic total occlusions: a 25-year experience from the Mayo Clinic
J Am Coll Cardiol
(2007)

P. Fefer et al.

Current perspectives on coronary chronic total occlusions: the Canadian Multicenter Chronic Total Occlusions Registry

J Am Coll Cardiol

(2012)

B.E. Claessen et al.

Evaluation of the effect of a concurrent chronic total occlusion on long-term mortality and left ventricular function in patients after primary percutaneous coronary intervention

JACC Cardiovasc Interv

(2009)

P.L. Whitlow et al.

Use of a novel crossing and re-entry system in coronary chronic total occlusions that have failed standard crossing techniques: results of the FAST-CTOs (Facilitated Antegrade Steering Technique in Chronic Total Occlusions) trial

JACC Cardiovasc Interv

(2012)

A. Hoye

Management of chronic total occlusion by percutaneous coronary intervention

Heart

(2012)

A. Liberati et al.

The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration

PLoS Med

(2009)

Cited by (50)

International randomized trial on the effect of revascularization or optimal medical therapy of chronic total coronary occlusions with myocardial ischemia - ISCHEMIA-CTO trial – rationale and design
2023, American Heart Journal
Chronic total occlusions (CTO) are frequent among patients with coronary artery disease. Revascularization with percutaneous coronary intervention (PCI) is safe and feasible in experienced hands. However, randomized data are needed to demonstrate symptomatic as well as prognostic effect of CTO-PCI compared to optimal medical therapy alone.
This trial aims to evaluate the effect of CTO PCI in patients with a CTO lesion and target vessel diameter ≥ 2.5 mm, and myocardial ischemia in the relevant territory. First, all patients are subjected to optimal medical therapy (OMT) for at least for 3 months and non-CTO lesions are managed according to guidelines. Subsequently, prior to randomization myocardial ischemia and quality of life (Seattle Questionnaire (SAQ)) is assessed. Patients are divided into two cohorts based on their SAQ score and randomized to either OMT alone or OMT and CTO-PCI. Cohort A is defined as Low- or asymptomatic patients with a quality-of-life score > 60 and/or CCS class < 2, and more than 10 % ischemia in the left ventricle (LV). Cohort B is symptomatic patients with a quality-of-life score < 60 or CCS class angina > 1 and at least ischemia in 5% of the LV. The primary end-point in cohort A is a composite of major adverse cardiac and cerebral events, hospitalization for heart failure and malignant ventricular arrhythmias. The primary endpoint in cohort B is difference in quality of life 6 months after randomization.
This trial is designed to investigate if CTO-PCI improves QoL and MACCE. Both positive and negative outcome of the trial will affect future guidelines and recommendations on how to treat patients with CTO.
Relation of Chronic Total Occlusion to In-Hospital Mortality in the Patients With Sudden Cardiac Arrest Due to Acute Coronary Syndrome
2019, American Journal of Cardiology
Although the presence of chronic total occlusion (CTO) has been associated with long-term mortality in the patients with ST-segment elevation myocardial infarction, the influence of having CTO on in-hospital mortality in sudden cardiac arrest (SCA)-acute coronary syndrome (ACS) patients has not been reported. Therefore, we examined the association between the presence of CTO and in-hospital mortality in those patients. Consecutive 106 SCA-ACS patients who received coronary angiography were retrospectively included. The factors associated with in-hospital mortality were analyzed. Among 106 patients, 40 (38%) patients died during hospitalization. Multivariate analysis revealed presence of CTO dependent on infarct-related artery (IRA-dependent-CTO) (hazard ratio [HR] = 2.88, p = 0.004), diabetes mellitus (HR = 2.04, p = 0.044), percutaneous cardiopulmonary support use (HR = 2.22, p = 0.045), successful recanalization (HR = 0.31, p = 0.004), and peak creatine kinase muscle-brain fraction (HR = 1.11, p < 0.001) were significantly associated with mortality. In conclusion, presence of IRA-dependent-CTO was significantly associated with in-hospital mortality in SCA-ACS patients.
Comparison of successful percutaneous coronary intervention versus optimal medical therapy in patients with coronary chronic total occlusion
2019, Journal of Cardiology
Citation Excerpt :
A previous study showed that incomplete revascularization by PCI leaving untreated CTOs led to higher 3-year mortality [12]. Many studies comparing successful CTO PCI versus failed CTO PCI also showed successful CTO PCI was associated with improved survival [6–8]. However, these studies are not direct data comparing the CTO PCI to medical treatment which might be essential to make decision for interventional cardiologists when they encounter patients with CTOs.
Chronic total occlusion (CTO) is a challenging entity in coronary interventions. With improvements in technology and techniques, success rates for percutaneous coronary intervention (PCI) of CTO continue to improve. However, the clinical benefits of PCI remain unclear. The aim of the study was to determine the effectiveness of successful PCI on clinical outcomes using drug-eluting stents in patients with CTO.
From 2004 to 2010, we analyzed 898 patients with at least one CTO who underwent successful PCI (n = 424, 448 lesions) or only medical treatment (n = 474, 519 lesions) from a multicenter registry. The primary outcome was all-cause death.
During a median of 2.2 years, incidence rate of all-cause death after successful PCI was lower than that after medical treatment (10.6% and 17.5%, p = 0.004). However, the multivariate Cox proportional hazards model showed that successful PCI was not associated with improvement in mortality compared to medical treatment [adjusted hazard ratio (HR) 0.84, 95% confidence interval (CI) 0.57–1.24, p = 0.38]. Comparable results were obtained after propensity-score matching. Subgroup analysis of propensity-score matched population demonstrated that patients with age under 65 years benefited from successful PCI (HR 0.25, 95% CI 0.08–0.75, p for interaction = 0.005).
In patients considered for CTO intervention, medical treatment appears to be associated with a similar mortality compared to successful PCI. Successful CTO PCI might be associated with survival benefit in younger patients compared to medical treatment.
Percutaneous revascularization of coronary chronic total occlusion: Toward a reappraisal of the available evidence
2017, Journal of Cardiology
Citation Excerpt :
Some meta-analyses included studies that used balloon angioplasty only [31,48]; the results of such studies cannot be extrapolated to the contemporary era of advanced stent technology and use of aggressive antithrombotic therapy. In one meta-analysis, the authors adopted the fixed-effect model, rather than the random-effects model, for analysis of outcome endpoints, despite the non-uniform distribution of effect sizes [49]. Moreover, in two meta-analyses, substantial heterogeneity existed among the included studies, for analysis of the index outcome [31,50].
Chronic total occlusion (CTO) is a challenging subset of coronary artery disease that is commonly encountered in real-world practice; it is associated with worse long-term prognosis. Observational studies suggest that percutaneous coronary intervention (PCI) for CTO is associated with reduction in myocardial ischemia and improvement in quality of life and left ventricular function. Some observational studies suggested that CTO-PCI is associated with improvement of the ‘hard’ clinical endpoints; others did not. Nearly all these studies compared the clinical outcome of successful versus failed PCI, rather than comparing the outcome of a whole CTO-PCI cohort versus a ‘true’ control group. Interestingly, in observational studies that compared the outcome of CTO-PCI versus optimal medical treatment, long-term mortality was comparable between the two strategies. In patients with multi-vessel disease and CTO, complete revascularization is more often achieved by coronary artery bypass grafting than by PCI; the SYNTAX score of these patients often favors surgical revascularization according to the current guidelines. The current guidelines reflect the divergence of opinion on the usefulness/benefit of CTO-PCI, mainly due to the lack of randomized trials. Evidence is awaited from three ongoing randomized controlled trials comparing PCI versus optimal medical treatment in the setting of CTO.
Dedicated CTO-PCI Centres: ‘If you Build it they will Come’
2016, Heart Lung and Circulation
Impact of percutaneous coronary intervention for chronic total occlusion in non-infarct-related arteries in patients with acute myocardial infarction (from the COREA-AMI Registry)
2016, American Journal of Cardiology
Chronic total occlusion (CTO) in a non–infarct-related artery (IRA) is an independent predictor of clinical outcomes in patients with acute myocardial infarction (AMI). This study evaluated the impact of successful percutaneous coronary intervention (PCI) for CTO of a non-IRA on the long-term clinical outcomes in patients with AMI. A total of 4,748 patients with AMI were consecutively enrolled in the Convergent Registry of Catholic and Chonnam University for AMI registry from January 2004 to December 2009. We enrolled 324 patients with CTO in a non-IRA. To adjust for baseline differences, propensity matching (96 matched pairs) was used to compare successful PCI and occluded CTO for the treatment of CTO in non-IRA. The primary clinical end points were all-cause mortality and a composite of the major adverse cardiac events, including cardiac death, MI, stroke, and any revascularization during the 5-year follow-up. Patients who received successful PCI for CTO of non-IRA had lower rates of all-cause mortality (16.7% vs 32.3%, hazard ratio 0.459, 95% CI 0.251 to 0.841, p = 0.012) and major adverse cardiac events (21.9% vs 55.2%, hazard ratio 0.311, 95% CI 0.187 to 0.516, p <0.001) compared with occluded CTO group. Subgroup analyses revealed that successful PCI resulted in a better mortality rate in patients with normal renal function compared to patients with chronic kidney disease (p = 0.010). In conclusion, successful PCI for CTO of non-IRA is associated with improved long-term clinical outcomes in patients with AMI.

View all citing articles on Scopus

: See page 524 for disclosure information.

View full text

Coronary artery diseaseMeta-Analysis of Effect on Mortality of Percutaneous Recanalization of Coronary Chronic Total Occlusions Using a Stent-Based Strategy

Section snippets

Methods

Results

Discussion

Disclosures

Am Heart J

J Am Coll Cardiol

JACC Cardiovasc Interv

JACC Cardiovasc Interv

Am J Cardiol

J Am Coll Cardiol

JACC Cardiovasc Interv

J Am Coll Cardiol

JACC Cardiovasc Interv

J Am Coll Cardiol

J Am Coll Cardiol

JACC Cardiovasc Interv

JACC Cardiovasc Interv

Management of chronic total occlusion by percutaneous coronary intervention

Heart

The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration

PLoS Med

Coronary artery disease
Meta-Analysis of Effect on Mortality of Percutaneous Recanalization of Coronary Chronic Total Occlusions Using a Stent-Based Strategy