Interv Akut Kardiol. 2023;22(4):166-172 | DOI: 10.36290/kar.2023.032

Current perspective on CTO PCI indications

Vojtěch Novotný
Kardiologické centrum Agel, a. s., Pardubice

The present article deals with the indications for revascularization of chronic total occlusions (CTO) of the coronary arteries. The introduction section briefly summarizes the history and development of CTO PCI. The main content of the paper is divided into three sections: the first one summarizes the current American and European societies of cardiology guidelines on CTO PCI; the second one provides a reflection on the most important aspects of the indication process from the most recent expert consensus; and the third one conveys the author's personal experience with indicating patients for CTO recanalization. The paper also includes an overview of randomized trials on CTO PCI.

Keywords: CTO, chronic total occlusion, PCI, complex PCI, indications, chronic coronary syndromes.

Received: March 30, 2023; Revised: November 20, 2023; Accepted: November 21, 2023; Published: November 28, 2023  Show citation

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Novotný V. Current perspective on CTO PCI indications. Interv Akut Kardiol. 2023;22(4):166-172. doi: 10.36290/kar.2023.032.
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    References

    1. Kober G, Hopf R, Reinemer H, Kaltenbach M. Langzeitergebnisse der transluminalen koronaren Angioplastie von chronischen Herzkranzgefässverschlüssen [Longterm results of transluminal coronary angioplasty of chronic coronary artery occlusions]. Z Kardiol. 1985;74:309-16.
    2. Sievert H, Köhler KP, Kober G, Kaltenbach M. Eröffnung chronischer Koronararterienverschlüsse mit einem Rekanalisationskatheter [Opening of chronic coronary artery occlusions with a recanalization catheter]. Dtsch Med Wochenschr. 1988;113:1703-7. Go to original source... Go to PubMed...
    3. Stone GW, Rutherford BD, McConahay DR, Johnson WL, Giorgi LV, Ligon RW, Hartzler GO. Procedural outcome of angioplasty for total coronary artery occlussion: an analysis of 971 lesions in 905 patients. J Am Coll Cardiol. 1990;15:849-56. Go to original source... Go to PubMed...
    4. Suero JA, Marso SP, Jones PG, et al. Procedural outcomes and long­‑term survival among patients undergoing percutaneous coronary intervention of a chronic total occlusion in native coronary arteries: a 20-year experience. J Am Coll Cardiol. 2001;38:409-14. Go to original source... Go to PubMed...
    5. Ybarra LF, Rinfret S, Brilakis ES. et al. Chronic Total Occlusion Academic Research Consortium. Definitions and Clinical Trial Design Principles for Coronary Artery Chronic Total Occlusion Therapies: CTO­‑ARC Consensus Recommendations. Circulation. 2021 Feb 2;143(5):479-500. Go to original source... Go to PubMed...
    6. Fefer P, Knudtson ML, Cheema AN, et al. Current perspectives on coronary chronic total occlusions: the Canadian Multicenter Chronic Total Occlusions Registry. J Am Coll Cardiol. 2012;59:991-7. Go to original source... Go to PubMed...
    7. Surmely JF, Katoh O, Tsuchikane E, Nasu K, Suzuki T. Coronary septal collaterals as an access for the retrograde approach in the percutaneous treatment of coronary chronic total occlusions. Catheter Cardiovasc Interv. 2007;69:826-32. Go to original source... Go to PubMed...
    8. Colombo A, Mikhail GW, Michev I, et al. Treating chronic total occlusions using subintimal tracking and re­‑entry: the STAR technique. Catheter Cardiovasc Interv. 2005;64:407-11. Go to original source... Go to PubMed...
    9. Lombardi WL. Retrograde PCI: what will they think of next. J Invasive Cardiol. 2009;21:543.
    10. Werner GS, Schofer J, Sievert H, Kugler C, Reifart NJ. Multicentre experience with the BridgePoint devices to facilitate recanalisation of chronic total coronary occlusions through controlled subintimal re­‑entry. EuroIntervention. 2011;7:192-200. Go to original source... Go to PubMed...
    11. Christopoulos G, Karmpaliotis D, Alaswad K, et al. Application and outcomes of a hybrid approach to chronic total occlusion percutaneous coronary intervention in a contemporary multicenter US registry. Int J Cardiol. 2015;198:222-8. Go to original source... Go to PubMed...
    12. Råmunddal T, Hoebers LP, Henriques JPS, et al. Prognostic Impact of Chronic Total Occlusions: A Report From SCAAR (Swedish Coronary Angiography and Angioplasty Registry). JACC Cardiovasc Interv. 2016;9:1535-44. Go to original source... Go to PubMed...
    13. Banning AP, Serruys P, De Maria GL, et al. Five­‑year outcomes after state­‑of­‑the­‑art percutaneous coronary revascularization in patients with de novo three­‑vessel disease: final results of the SYNTAX II study. Eur Heart J. 2022;43:1307-16. Go to original source... Go to PubMed...
    14. Lawton JS, Tamis­‑Holland JE, Bangalore S, et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 Jan 18;145(3):e4-e17. Go to original source... Go to PubMed...
    15. Neumann FJ, Sousa­‑Uva M, Ahlsson A, et al.; ESC Scientific Document Group. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J. 2019 Jan 7;40(2):87-165. Go to original source... Go to PubMed...
    16. Di Mario C, Mashayekhi KA, Garbo R, et al. Recanalisation of coronary chronic total occlusions. EuroIntervention. 2022 Sep 20;18(7):535-561. Go to original source... Go to PubMed...
    17. Tsai TT, Stanislawski MA, Shunk KA, et al. Contemporary Incidence, Management, and Long­‑Term Outcomes of Percutaneous Coronary Interventions for Chronic Coronary Artery Total Occlusions: Insights From the VA CART Program. JACC Cardiovasc Interv. 2017 May 8;10(9):866-875. Go to original source... Go to PubMed...
    18. Tajti P, Burke MN, Karmpaliotis D, et al. Prevalence and Outcomes of Percutaneous Coronary Interventions for Ostial Chronic Total Occlusions: Insights From a Multicenter Chronic Total Occlusion Registry. Can J Cardiol. 2018 Oct;34(10):1264-1274. Go to original source... Go to PubMed...
    19. Sapontis J, Salisbury AC, Yeh RW, et al. Early Procedural and Health Status Outcomes After Chronic Total Occlusion Angioplasty: A Report From the OPEN­‑CTO Registry (Outcomes, Patient Health Status, and Efficiency in Chronic Total Occlusion Hybrid Procedures). JACC Cardiovasc Interv. 2017 Aug 14;10(15):1523-1534. Go to original source... Go to PubMed...
    20. Stone GW, Reifart NJ, Moussa I, et al. Percutaneous recanalization of chronically occluded coronary arteries: a consensus document: part II. Circulation. 2005 Oct 18;112(16):2530-7. Go to original source... Go to PubMed...
    21. Henriques JP, Hoebers LP, Råmunddal T, et al. EXPLORE Trial Investigators. Percutaneous Intervention for Concurrent Chronic Total Occlusions in Patients With STEMI: The EXPLORE Trial. J Am Coll Cardiol. 2016 Oct 11;68(15):1622-1632. Go to original source... Go to PubMed...
    22. Mashayekhi K, Nührenberg TG, Toma A, et al. A Randomized Trial to Assess Regional Left Ventricular Function After Stent Implantation in Chronic Total Occlusion: The REVASC Trial. JACC Cardiovasc Interv. 2018 Oct 8;11(19):1982-1991. Go to original source... Go to PubMed...
    23. Lee SW, Lee PH, Ahn JM, et al. Randomized Trial Evaluating Percutaneous Coronary Intervention for the Treatment of Chronic Total Occlusion. Circulation. 2019 Apr 2;139(14):1674-1683. Go to original source... Go to PubMed...
    24. Werner GS, Martin­‑Yuste V, Hildick­‑Smith D, et al.; EUROCTO trial investigators. A randomized multicentre trial to compare revascularization with optimal medical therapy for the treatment of chronic total coronary occlusions. Eur Heart J. 2018 Jul 7;39(26):2484-2493. Go to original source... Go to PubMed...
    25. Christiansen E. ISCHEMIA­‑CTO Trial - Revascularisation or Optimal Medical Therapy of CTO (ISCHEMIA­‑CTO). 2018. Available from: https://clinicaltrials.gov/ct2/show/NCT03563417.
    26. Minneapolis Heart Institute Foundation. The SHINE­‑CTO Trial (SHINE­‑CTO). 2016. Available from: https://clinicaltrials.gov/ct2/show/NCT02784418.
    27. The NOrdic­‑Baltic Randomized Registry Study for Evaluation of PCI in Chronic Total Coronary Occlusion (NOBLE­‑CTO). 2018. Available from: https://clinicaltrials.gov/ct2/show/NCT03392415.
    28. Obedinskiy AA, Kretov EI, Boukhris M, et al. The IMPACTOR­‑CTO Trial. JACC Cardiovasc Interv. 2018 Jul 9;11(13):1309-1311. Go to original source... Go to PubMed...
    29. Knuuti J, Wijns W, Saraste A, et al. ESC Scientific Document Group. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J. 2020 Jan 14;41(3):407-477. Go to original source... Go to PubMed...
    30. Brilakis ES, Banerjee S, Karmpaliotis D, et al. Procedural outcomes of chronic total occlusion percutaneous coronary intervention: A report from the NCDR (National Cardiovascular Data Registry). JACC Cardiovasc Interv 2015;8:245-253. Go to original source... Go to PubMed...
    31. Maeremans J, Walsh S, Knaapen P, et al. The hybrid algorithm for treating chronic total occlusions in Europe: The RECHARGE registry. J Am Coll Cardiol. 2016;68:1958-1970. Go to original source... Go to PubMed...
    32. Galassi AR, Sianos G, Werner GS, et al. Euro CTO Club. Retrograde recanalization of chronic total occlusions in Europe: Procedural, in­‑hospital, and long­‑term outcomes from the multicenter ERCTO registry. J Am Coll Cardiol. 2015;65:2388-400. Go to original source... Go to PubMed...
    33. Christakopoulos GE, Christopoulos G, Carlino M, et al. Meta­‑analysis of clinical outcomes of patients who underwent percutaneous coronary interventions for chronic total occlusions. Am J Cardiol. 2015;115:1367-1375. Go to original source... Go to PubMed...
    34. Mehran R, Claessen BE, Godino C, et al. Multinational Chronic Total Occlusion Registry. Long­‑term outcome of percutaneous coronary intervention for chronic total occlusions. JACC Cardiovasc Interv. 2011;4:952-961. Go to original source... Go to PubMed...
    35. Claessen BE, Dangas GD, Godino C, et al. Multinational Cto Registry. Long­‑term clinical outcomes of percutaneous coronary intervention for chronic total occlusions in patients with versus without diabetes mellitus. Am J Cardiol. 2011;108:924-931. Go to original source... Go to PubMed...
    36. Jones DA, Weerackody R, Rathod K, et al. Successful recanalization of chronic total occlusions is associated with improved long­‑term survival. JACC Cardiovasc Interv 2012;5:380-388. Go to original source... Go to PubMed...
    37. Grantham JA, Jones PG, Cannon L, et al. Quantifying the early health status benefits of successful chronic total occlusion recanalization: Results from the FlowCardia's Approach to Chronic Total Occlusion Recanalization (FACTOR) Trial. Circ Cardiovasc Qual Outcomes. 2010;3:284-290. Go to original source... Go to PubMed...
    38. Joyal D, Afilalo J, Rinfret S. Effectiveness of recanalization of chronic total occlusions: A systematic review and meta­‑analysis. Am Heart J. 2010;160:179-187. Go to original source... Go to PubMed...
    39. Borgia F, Viceconte N, Ali O, et al. Improved cardiac survival, freedom from MACE and angina­‑related quality of life after successful percutaneous recanalization of coronary artery chronic total occlusions. Int J Cardiol. 2012;161:31-8. Go to original source... Go to PubMed...
    40. George S, Cockburn J, Clayton TC, et al.; British Cardiovascular Intervention Society; National Institute for Cardiovascular Outcomes Research. Long­‑term follow­‑up of elective chronic total coronary occlusion angioplasty: analysis from the U.K. Central Cardiac Audit Database. J Am Coll Cardiol. 2014;64:235-43. Go to original source... Go to PubMed...
    41. Goel PK, Khanna R, Pandey C, Ashfaq F. Long­‑term outcomes post chronic total occlusion intervention­‑implications of completeness of revascularization. J Interv Cardiol. 2018;31:293-301. Go to original source... Go to PubMed...
    42. Tomasello SD, Boukhris M, Giubilato S, et al. Management strategies in patients affected by chronic total occlusions: results from the Italian Registry of Chronic Total Occlusions. Eur Heart J. 2015;36:3189-98. Go to original source... Go to PubMed...
    43. Park TK, Lee SH, Choi KH, et al. Late Survival Benefit of Percutaneous Coronary Intervention Compared With Medical Therapy in Patients With Coronary Chronic Total Occlusion: A 10-Year Follow­‑Up Study. J Am Heart Assoc. 2021;10:e019022. Go to original source... Go to PubMed...
    44. Juricic SA, Tesic MB, Galassi AR, et al. Randomized Controlled Comparison of Optimal Medical Therapy with Percutaneous Recanalization of Chronic Total Occlusion (COMET­‑CTO). Int Heart J. 2021;62:16-22. Go to original source...
    45. Brilakis ES, Mashayekhi K, Burke MN. How DECISION­‑CTO Can Help Guide the Decision to Perform Chronic Total Occlusion Percutaneous Coronary Intervention. Circulation. 2019 Apr 2;139(14):1684-1687. Go to original source... Go to PubMed...
    46. Galassi AR, Boukhris M, Toma A, et al. Percutaneous Coronary Intervention of Chronic Total Occlusions in Patients With Low Left Ventricular Ejection Fraction. JACC Cardiovasc Interv. 2017;10:2158-70. Go to original source... Go to PubMed...
    47. Werner GS, Surber R, Kuethe F, et al. Collaterals and the recovery of left ventricular function after recanalization of a chronic total coronary occlusion. Am Heart J. 2005;149:129-37. Go to original source... Go to PubMed...
    48. de Winter RW, Schumacher SP, van Diemen PA, et al. Impact of percutaneous coronary intervention of chronic total occlusions on absolute perfusion in remote myocardium. EuroIntervention. 2022;18:e314-23. Go to original source... Go to PubMed...
    49. Maron DJ, Hochman JS, Reynolds HR, et al. ISCHEMIA Research Group. Initial Invasive or Conservative Strategy for Stable Coronary Disease. N Engl J Med. 2020;382:1395-407. Go to original source... Go to PubMed...
    50. Navarese EP, Lansky AJ, Kereiakes DJ, et al. Cardiac mortality in patients randomised to elective coronary revascularisation plus medical therapy or medical therapy alone: a systematic review and meta­‑analysis. Eur Heart J. 2021;42:4638-51. Go to original source... Go to PubMed...
    51. Al­‑Lamee R, Jacobs AK. ISCHEMIA Trial: Was It Worth the Wait? Circulation. 2020;142:517-9. Go to original source... Go to PubMed...
    52. King SB 3rd. The ISCHEMIA Trial: "Stable Angina Cured". Cardiovasc Revasc Med. 2020;21:254-55. Go to original source... Go to PubMed...
    53. Velazquez EJ, Lee KL, Deja MA, et al. STICH Investigators. Coronary­‑artery bypass surgery in patients with left ventricular dysfunction. N Engl J Med. 2011;364:1607-16. Go to original source... Go to PubMed...
    54. Velazquez EJ, Lee KL, Jones RH, et al. STICHES Investigators. Coronary­‑Artery Bypass Surgery in Patients with Ischemic Cardiomyopathy. N Engl J Med. 2016;374:1511-20. Go to original source... Go to PubMed...
    55. Fujii T, Sakai K, Nakano M, et al. Impact of the origin of the collateral feeding donor artery on short­‑term mortality in ST­‑elevation myocardial infarction with comorbid chronic total occlusion. Int J Cardiol. 2016;218:158-63. Go to original source... Go to PubMed...
    56. Kral A, Belohlavek J, Rob D, Smalcova J. Abstract 13434: Chronic Total Occlusions in Refractory Cardiac Arrest Patients. Available from: https://doi.org/10.1161/circ.144.suppl_2.13434. Go to original source...
    57. Antman EM, Braunwald E. Managing Stable Ischemic Heart Disease. N Engl J Med. 2020;382:1468-70. Go to original source... Go to PubMed...
    58. Schumacher SP, Stuijfzand WJ, Opolski MP, et al. Percutaneous Coronary Intervention of Chronic Total Occlusions: When and How to Treat. Cardiovasc Revasc Med. 2019;20:513-22. Go to original source... Go to PubMed...
    59. Abdullah SM, Hastings JL, Amsavelu S, et al. Percutaneous Coronary Intervention of Coronary Chronic Total Occlusions Improves Peak Oxygen Uptake during Cardiopulmonary Exercise Testing. J Invasive Cardiol. 2017;29:83-91. Go to original source...
    60. Mashayekhi K, Neuser H, Kraus A, et al. Successful Percutaneous Coronary Intervention Improves Cardiopulmonary Exercise Capacity in Patients With Chronic Total Occlusions. J Am Coll Cardiol. 2017;69:1095-6. Go to original source... Go to PubMed...
    61. Qintar M, Grantham JA, Sapontis J, et al. Dyspnea Among Patients With Chronic Total Occlusions Undergoing Percutaneous Coronary Intervention: Prevalence and Predictors of Improvement. Circ Cardiovasc Qual Outcomes. 2017; 10:e003665. Go to original source... Go to PubMed...
    62. Rösner A, Avenarius D, Malm S, et al. Severe regional myocardial dysfunction by stress echocardiography does not predict the presence of transmural scarring in chronic coronary artery disease. Eur Heart J Cardiovasc Imaging. 2015;16:1074-81. Go to original source... Go to PubMed...
    63. Bucciarelli­‑Ducci C, Auger D, Di Mario C, et al. CMR Guidance for Recanalization of Coronary Chronic Total Occlusion. JACC Cardiovasc Imaging. 2016;9:547-56. Go to original source... Go to PubMed...
    64. Megaly M, Brilakis ES, Abdelsalam M, et al. Impact of Chronic Total Occlusion Revascularization on Left Ventricular Function Assessed by Cardiac Magnetic Resonance. JACC Cardiovasc Imaging. 2021;14:1076-8. Go to original source... Go to PubMed...
    65. Allahwala UK, Brilakis ES, Kiat H, et al. The indications and utility of adjunctive imaging modalities for chronic total occlusion (CTO) intervention. J Nucl Cardiol. 2021;28:2597-608. Go to original source... Go to PubMed...
    66. Schumacher SP, Everaars H, Stuijfzand WJ, et al. Viability and functional recovery after chronic total occlusion percutaneous coronary intervention. Catheter Cardiovasc Interv. 2021;98:E668-76. Go to original source... Go to PubMed...
    67. Schumacher SP, Everaars H, Stuijfzand WJ, et al. Coronary collaterals and myocardial viability in patients with chronic total occlusions. EuroIntervention. 2020;16:e453-61. Go to original source... Go to PubMed...
    68. Serruys PW, Morice MC, Kappetein AP, et al.; SYNTAX Investigators. Percutaneous coronary intervention versus coronary­‑artery bypass grafting for severe coronary artery disease. N Engl J Med. 2009;360:961-72. Go to original source... Go to PubMed...
    69. Mohr FW, Morice MC, Kappetein AP, et al. Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three­‑vessel disease and left main coronary disease: 5-year follow­‑up of the randomised, clinical SYNTAX trial. Lancet. 2013;381:629-38. Go to original source... Go to PubMed...
    70. Thuijs DFJM, Kappetein AP, Serruys PW, et al.; SYNTAX Extended Survival Investigators. Percutaneous coronary intervention versus coronary artery bypass grafting in patients with threevessel or left main coronary artery disease: 10-year follow­‑up of the multicentre randomised controlled SYNTAX trial. Lancet. 2019;394:1325-34. Go to original source... Go to PubMed...

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