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Successful CTO PCI linked to decreased mortality, CABG risk
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Recently published data demonstrated a high success rate of elective chronic total occlusion PCI as well as an association between successful procedures and decreased risks for death and subsequent CABG.
Using data from the VA Clinical Assessment Reporting and Tracking program, the researchers evaluated consecutive patients undergoing coronary angiography at 79 VA cath labs from 2007 to 2013. They identified 111,273 patients with obstructive CAD, 29,399 (26.4%) of whom had at least one CTO.
Elective CTO PCI was performed in 2,394 (8.1%) of the patients with at least one CTO. The researchers reported that 42.4% of treated CTOs were in the right coronary artery distribution, 23.5% in the left anterior descending coronary artery and 15.9% in the left circumflex coronary artery. The average lesion length was 20 mm.
The rate of overall procedural success was 79.7%, according to the data, with a slightly higher technical success rate of 79.8%. In successful procedures, 80.8% involved drug-eluting stents and 27.8% required two or more stents. Periprocedural complications occurred more often in patients with unsuccessfully treated lesions (7.5% vs. 3.5%), including dissections and perforations.
The likelihood of successful CTO PCI increased during the study period (OR = 1.08; 95% CI, 1.01-1.16) but decreased with increasing numbers of CTOs treated (OR = 0.55; 95% CI, 0.38-0.81). The odds of a successful procedure were also lower among black patients compared with white patients (OR = 0.68; 95% CI, 0.5-0.92).
After adjustment for baseline characteristics, successful CTO PCI vs. unsuccessful CTO PCI was linked to a decreased risk for mortality (HR = 0.67; 95% CI, 0.47-0.95) and a decreased risk for CABG (HR = 0.14; 95% CI, 0.08-0.24) after 2 years. Risk for hospitalization for MI did not differ significantly between successful and unsuccessful procedures (HR = 0.89; 95% CI, 0.58-1.36).
“These results are consistent with prior studies suggesting improved survival with successful CTO PCI procedures. However, these findings need to be validated in prospective randomized control trials,” the researchers wrote.
In an accompanying editorial, J. Aaron Grantham, MD, of the University of Missouri Kansas City and Saint Luke’s Mid America Heart Institute, noted that the size of the study population lends strength to its data, but not all clinicians would consider changing clinical practice based on the results.
“[The findings] provide the CTO PCI ‘believers’ with further reassurances that treating asymptomatic CTO patients with PCI might provide some benefits. Unfortunately, for the ‘nonbelievers,’ who might also call themselves ‘evidence-based’ clinicians, yet another retrospective, confounded analysis, no matter how big, is not better,” Grantham wrote.
Only appropriately powered randomized trials will provide definitive data on the potential survival benefit of CTO PCI, according to Grantham.
“Until then, ‘believers’ should explain to their patients the limited evidence that exists, and ‘nonbelievers’ will likely tell their patients that ‘no evidence exists’ to support PCI as a therapeutic option for asymptomatic patients with CTOs,” he wrote. – by Melissa Foster
Disclosure: The researchers report no relevant financial disclosures. Grantham reports receiving speaking fees and honoraria from Abbott Vascular, Asahi Intecc, Boston Scientific and St. Jude Medical; institutional research grant support from Boston Scientific; institutional educational grant support from Abbott Vascular, Asahi Intecc, Boston Scientific and Vascular Solutions; and being a part-time employee of Corindus Vascular Robotics.
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