Revascularization of chronic total occlusions: time to reconsider?

Up to 20% of all coronary angiograms reveal coronary chronic total occlusions (CTOs). The lack of robust type A evidence with hard clinical outcomes on the benefits of CTO revascularization has hampered attempts to develop recommendations regarding the optimal management of CTOs. This review presents issues surrounding CTO revascularization within the framework of the appropriate use criteria ratings. Appropriate use criteria ratings downgrade CTO percutaneous coronary intervention revascularization relative to non-CTOs and to surgical revascularization. Specific aspects of CTO revascularization include ischemic burden, impact of revascularization on quality of life, risks in CTO revascularization, and the importance of complete revascularization. Contemporary data suggest CTO revascularization may have substantial impact on patient outcomes; thus, revascularization should likely be held to similar criteria as nonocclusive lesions. However, additional large clinical trial data are required to more definitively determine CTO revascularization guidelines.