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Prognostic Impact of Target Vessel in Chronic Total Occlusions: A Population-Based Cohort Study
Emil Nielsen Holck1, Lars Jakosen2, Lone Juul-Hune Mogensen3
1Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Cardiology, Hospitalsenheden Midt, Viborg, Denmark.
Insights
Successful percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) in the left anterior descending (LAD) artery shows similar outcomes to non-CTO LAD PCI. However, unsuccessful LAD CTO PCI is linked to significantly poorer prognosis, highlighting LAD CTO as a high-risk condition.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Clinical Outcomes Research
Background:
- Percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) in the left anterior descending (LAD) artery aims to improve patient outcomes.
- Existing data suggest variable benefits of invasive treatment for non-CTO LAD lesions.
- The prognostic impact of CTO revascularization, stratified by target vessel, requires further investigation compared to non-CTO LAD PCI.
Purpose of the Study:
- To investigate the prognostic impact of CTO revascularization stratified by target treated vessel compared with non-CTO LAD PCI.
- To test the hypothesis that successful PCI of LAD CTO and non-LAD CTO, and unsuccessful non-LAD CTO, are associated with similar prognoses as non-CTO LAD lesions.
- To determine if unsuccessful LAD CTO PCI is associated with a poorer prognosis.
Main Methods:
- Population-based cohort study including 21,141 patients undergoing PCI from 2009 to 2019 in the Central Denmark Region.
- Exclusion of patients with acute myocardial infarction within 30 days.
- Stratification of CTO patients by occluded vessel and procedural success, with long-term all-cause mortality as the primary endpoint.
Main Results:
- Successful PCI for both LAD CTO and non-LAD CTO showed similar adjusted risks for all-cause mortality compared to non-CTO LAD PCI (LAD CTO HR 1.14 [0.90-1.44]; non-LAD CTO HR 1.09 [0.95-1.27]).
- Unsuccessful LAD CTO PCI was associated with a significantly higher risk of all-cause mortality (HR 1.88 [1.33-2.65]) compared to non-CTO LAD PCI.
- Unsuccessful non-LAD CTO PCI did not show a significantly higher risk (HR 1.26 [0.97-1.63]) compared to non-CTO LAD PCI.
Conclusions:
- Successful PCI for both LAD and non-LAD CTOs confers a similar long-term prognosis as non-CTO LAD PCI.
- Only unsuccessful LAD CTO PCI is associated with a poorer prognosis, identifying LAD CTO patients as a high-risk population.
- Dedicated CTO trials are needed to confirm these findings and inform guideline recommendations for LAD CTO management.
Abstract:
Successful percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) in the coronary arteries in the left anterior descending (LAD) artery is associated with better outcome than unsuccessful PCI. Randomized data have not found invasive treatment of non-CTO LAD lesion to be associated with better outcome. This study aimed to investigate the prognostic impact of CTO revascularization stratified on target treated vessel compared with non-CTO LAD PCI. The hypothesis was that successful PCI of LAD CTO and non-LAD CTO and unsuccessful non-LAD CTO were associated with the same prognosis as non-CTO LAD lesions, whereas patients with unsuccessful LAD CTO were associated with a poorer prognosis. The study was a population-based cohort study, including consecutive patients who underwent PCI from 2009 to 2019 in the Central Denmark Region. Patients with acute myocardial infarction within 30 days were excluded. Patients with CTO were stratified by occluded vessel and procedural success. The primary end point was long-term all-cause mortality and was calculated as a hazard ratio with a 95% confidence interval. Secondary end points were myocardial infarction and target vessel revascularization. In total, 21,141 patients were screened, 4,518 had non-CTO LAD PCI, and 1,475 had CTO PCI. The median (interquartile range) follow-up was 5.8 years (3.6 to 8.8). In the successful CTO groups, the adjusted risk for all-cause mortality was equal to patients with non-CTO LAD (LAD CTO hazard ratio [95% confidence interval] 1.14 [0.90 to 1.44], non-LAD CTO 1.09 [0.95 to 1.27]). Patients with unsuccessful LAD CTO had a higher risk than patients with non-CTO LAD, whereas unsuccessful non-LAD CTO had not (unsuccessful LAD 1.88 [1.33 to 2.65], unsuccessful non-LAD 1.26 [0.97 to 1.63]). In conclusion, successful LAD and non-LAD CTO PCI had the same prognosis as non-CTO LAD PCI, whereas only unsuccessful LAD CTO PCI had a poorer prognosis. Patients with LAD CTO are a high-risk population, and dedicated CTO trials are needed to confirm this finding and establish guideline recommendations.
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