Management of Chronic Total Occlusion of Coronary Artery

Chronic total occlusion (CTO) of a coronary artery is typically defined as a completely occluded artery without any antegrade flow and a duration of at least 3 months. We reviewed the current literature describing the optimal management of CTO including the role of revascularization and choice of modality, i.e., percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery. Databases (PubMed, the Cochrane Library, Embase, EBSCO, Web of Science, and CINAHL) were searched and relevant studies of patients with CTO were selected for review. The prevalence of coronary artery CTOs is approximately 25% among patients undergoing coronary angiography for angina. Available data suggests that PCI of CTO can be a technically complex procedure with relatively lower success rates compared with non-CTO PCI and typically associated with a higher complication rate especially at nonspecialized centers. Furthermore, successful CTO-PCI is associated with symptomatic improvement but does not appear to improve mortality, myocardial infarction, stroke, and repeat revascularization rates. Based on contemporary data, PCI of CTO lesions may be considered in patients with incapacitating angina despite treatment with optimal guideline-directed medical therapy and in whom based on coronary anatomy there is a reasonable chance of technical success with an acceptable risk.