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Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
The evidence base for revascularisation of chronic total occlusions
Alan Bagnall, Ioakim Spyridopoulos1
1Department of Cardiology, The Freeman Hospital, Freeman Road, Newcastle upon Tyne, NE7 7DN. UK. Alan.Bagnall@nuth.nhs.uk.
Insights
Treating chronic total occlusions (CTOs) in ischaemic heart disease can improve survival and quality of life. Despite advances, percutaneous coronary intervention (PCI) for CTOs is underutilized, even when surgery poses high risks.
Area of Science:
- Cardiology
- Interventional Cardiology
- Ischaemic Heart Disease
Background:
- Chronic total occlusions (CTOs) are challenging lesions in ischaemic heart disease.
- CTOs are a primary reason for choosing coronary artery bypass surgery.
- Physicians recognize the importance of CTOs in heart disease management.
Purpose of the Study:
- To review the link between CTOs, angina, ischaemia, and left ventricular dysfunction.
- To explore evidence on CTO treatment improving quality of life and prognosis.
- To address the reluctance in performing percutaneous coronary intervention (PCI) for CTOs.
Main Methods:
- Review of existing literature and clinical data.
- Analysis of the relationship between CTOs and cardiac dysfunction.
- Evaluation of the impact of CTO treatment on patient outcomes.
Main Results:
- Significant advances in CTO PCI success rates and safety have been achieved.
- Evidence supports a survival benefit for patients undergoing successful CTO PCI.
- Underutilization of CTO PCI persists, particularly in high-risk or non-proximal lesions.
Conclusions:
- Successful CTO PCI offers a survival benefit and improves quality of life.
- Further exploration of CTO PCI is warranted, especially when surgery is not ideal.
- Addressing the reluctance towards CTO PCI can optimize patient care for ischaemic heart disease.
Abstract:
When patients with ischaemic heart disease are considered for revascularisation the Heart Team's aim is to choose a therapy that will provide complete relief of angina for an acceptable procedural risk. Complete functional revascularisation of ischaemic myocardium is thus the goal and for this reason the presence of a chronic total occlusion (CTO) - which remain the most technically challenging lesions to revascularise percutaneously - is the most common reason for selecting coronary artery bypass surgery. From the behaviour of Heart Teams it is clear that physicians believe that CTOs are important. Yet when faced with patients with CTOs for whom surgery appears excessive (e.g. nonproximal LAD) or too high risk, there remains a reluctance to undertake CTO PCI, despite significant recent advances in procedural success and safety and a considerable body of evidence supporting a survival benefit following successful CTO PCI. This article reviews the relationship between CTOs, symptoms of angina, ischaemia and left ventricular dysfunction and further explores the evidence relating their treatment to improved quality of life and prognosis in patients with these features.
