Update on the Management of Chronic Total Occlusions in Coronary Artery Disease

Chronic total occlusions (CTOs) are found in about a third of patients with coronary artery disease (CAD) and can pose a significant challenge during percutaneous revascularization. However, advances in CTO percutaneous coronary intervention (PCI) strategies, devices, and algorithms have led to significant improvements in successful treatment of CTOs. This review summarizes current management of CTOs in the context of modern PCI techniques and current evidence.

The hybrid algorithm now provides a standardized, teachable approach to CTO PCI, and success rates are approximately 90% in experienced hands. The first randomized controlled trial in patients with CTOs recently reported that patients with ST elevation myocardial infarction (STEMI) and a CTO in the non-culprit vessel showed an improvement in ejection fraction in patients undergoing CTO PCI of the LAD, but not other vessels. Updated data from the SYNTAX trial showed a benefit with complete revascularization in patients with coronary artery disease (CAD). Incomplete revascularization of CTOs in the PCI group may explain some of the benefit seen with CABG over PCI in patients with complex coronary disease. Contemporary CTO registries have reported success rates of approximately 90%, and the OPEN-CTO registry updates our understanding of CTO PCI complication rates and outcomes. The available evidence highlights the potential benefits of CTO PCI in patients with an indication for revascularization. Technological advancements have paved the way for success rates approaching 90% at high-volume centers, but further studies evaluating outcomes following CTO PCI are needed, with several currently underway.