Percutaneous coronary intervention for chronic total occlusions: the Thoraxcenter experience 1992-2002

Chronic total occlusions (CTOs) are commonly found on diagnostic angiography, and there is some evidence from one study that successful percutaneous revascularization leads to an improvement in long-term survival rates. However, this study included patients treated for unstable angina with short-duration occlusion, and stent implantation was utilized in only 7%. We re-evaluated the long-term outcomes of a large consecutive series of patients with a CTO of >1-month duration treated at our centre, with stent implantation utilized in the majority.

All patients treated with percutaneous coronary intervention (PCI) between 1992 and 2002 were retrospectively identified from a dedicated database. A total of 874 consecutive patients were treated for 885 CTO lesions. Mean follow-up time was 4.47 +/- 2.69 years (median 4.10 years). Patients were evaluated for the occurrence of major adverse cardiac events (MACE) comprising death, acute myocardial infarction, and need for repeat revascularization with either coronary artery bypass surgery or PCI. Successful revascularization was achieved in 576 lesions (65.1%), in which stent implantation was used in 81.0%. At 30 days, the overall MACE rate was significantly lower in those patients with a successful recanalization (5.5 vs. 14.8%, P < 0.00001). At 5 years, survival was significantly higher in those patients with a successful revascularization (93.5 vs. 88.0%, P = 0.02). In addition, there was a significantly higher survival free of MACE (63.7 vs. 41.7%, P < 0.0001), with the majority of events reflecting the need for repeat intervention. Independent predictors for survival were successful revascularization, lower age, and the absence of diabetes mellitus and multivessel disease.

Successful percutaneous revascularization of a CTO leads to a significantly improved survival rate and a reduction in major adverse events at 5 years. Most events relate to the need for repeat reintervention, and the introduction of drug-eluting stents, with low-restenosis rates, encourages the development of technologies to improve recanalization success rates. However, failed recanalization may be associated acutely with an adverse event, and new technologies must focus on a safe approach to successful recanalization.