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Study highlights no difference in mortality risk between successful, failed CTO PCI
Risk for long-term mortality was similar among patients with native chronic total occlusions who underwent successful or failed PCI. However, successful chronic total occlusion PCI was linked to a reduced need for subsequent CABG, according to recent findings.
Researchers in Korea evaluated 1,173 consecutive patients enrolled in the CTO registry, in whom CTO PCI was attempted between March 2003 and May 2014. About 83% of patients were men and the mean age was 60 years.
Successful CTO PCI was defined as successful recanalization of the target CTO lesion with drug-eluting stent implantation, restoration of TIMI flow grade 2 and residual diameter stenosis of less than 30% on visual evaluation. Clinical follow-up occurred at 1 month, 6 months and 1 year, and annually thereafter. The researchers reviewed digital angiograms for CTO length, total lesion length of the target vessel and total stent length.
The primary safety endpoints were all-cause mortality and a composite of all-cause mortality or Q-wave MI.According to the results, successful stent implantation was achieved in 1,004 patients and failed CTO PCI occurred in 169 patients. During a median follow-up of 4.6 years, the researchers recorded 101 deaths, 68 of which were associated with CV causes. Q-wave MI occurred in 17 patients, and 11 patients experienced a stroke. Target vessel revascularization was performed in 78 patients, and 33 patients underwent subsequent CABG.
There was no difference between the two groups in the cumulative rate of all-cause mortality (8% successful vs. 7.1% failed; P = .83) or the composite of death or Q-wave MI (9% successful vs. 8.5% failed; P = .94). The researchers observed similar incidences of cardiac death, Q-wave MI and stroke between the groups. Patients in the failed CTO PCI group had significantly higher rates of TVR (4.4% successful vs. 20.9% failed; P < .001) and CABG (0.4% successful vs. 16.7% failed; P < .0001). The failed CTO PCI group had significantly higher overall rates of any coronary revascularization and the composite of death, Q-wave MI or TVR. The failed CTO PCI group also had a significantly higher adjusted risk for both of these outcomes (TVR: HR = 0.15; 95% CI, 0.1-0.25; P < .001; CABG: HR = 0.02; 95% CI, 0.006-0.06; P < .001). Patients who underwent complete revascularization for non-CTO vessels did not differ in risk for death or death/MI compared with those who underwent successful recanalization of residual CTO and those who did not.
George W. Vetrovec
“The revascularization strategy for non-CTO vessels, high frequency of subsequent CABG in patients with failed PCI and high procedural success with low life-threatening complication rate may have all contributed to our study finding,” the researchers wrote.
Future randomized studies will be needed to accurately characterize the utility of CTO PCI, George W. Vetrovec, MD, from the Virginia Commonwealth University Pauley Heart Center and a Cardiology Today Editorial Board member, wrote in a related editorial.
“Given the expense, risk and management issues related to CTO PCI in optimal coronary disease management, continued retrospective comparative trials of successful vs. unsuccessful CTO PCI seem unlikely to define the value of this technology,” he wrote. “It appears time to seriously initiate plans for a randomized trial.” – by Jennifer Byrne
Disclosure: The researchers report no relevant financial disclosures. Vetrovec reports consulting for Abiomed.