Treatment of coronary chronic total occlusions (CTO) remains a challenge that is the leading cause of failed percutaneous coronary interventional procedures (PCI) and is the leading indication for coronary bypass graft surgery (CABG) referrals. Advent of new and dedicated CTO crossing wires, reentry devices and crossing catheters, combined with new and innovative techniques have led to a significant improvement in success rates of CTO treatment. Use of drug eluting stents (DES) and its use in CTO treatment has allowed long-term durability of the procedural successes.
Despite the emerging enthusiasm coupled with increasing success rates of CTO treatment, the evidence base for CTO treatment is relatively small and has been largely limited to comparisons between DES and bare metal stents (BMS). Binary angiographic restenosis is lower with DES compared to BMS (odds ratio 0.15, 95% CI 0.08, 0.26, P for heterogeneity = 0.20) and sirolimus eluting stents (SES) have been shown in one study to have a lower binary angiographic restenosis rate compared to paclitaxel eluting stent (PES) (9.4% SES versus 28.6% PES, P=0.020). Stent thrombosis rates are similar for both DES and BMS. Long-term (36 month) outcomes of death, MI and stent thrombosis remained similar between BMS and DES patients. Large, high-quality, prospective strategy trials are needed to provide more information on the validity of treating CTO, on role of DES in CTO and to determine if use of second generation DES could provide even more favorable outcomes.
These data on the initial success in the treatment of coronary CTO need to be balanced against potential risk of complications. Risk of serious and life-threatening complications like coronary perforations and large dissections are more frequent compared to a non-CTO PCI. On the same note, early recognition and ability to promptly deal with these complications are critical to CTO treatment plans.
Substantial familiarity and training prior to attempting CTO are crucial, along with a minimum of 50 CTO procedures a year. From our personal experience and that of many prior CTO experts, a mentoring program along with development of a core group of institutional or regional core group of CTO experts are necessary to achieve high and reproducible success rates with minimal complications.
Despite the emerging enthusiasm coupled with increasing success rates of CTO treatment, the evidence base for CTO treatment is relatively small and has been largely limited to comparisons between DES and bare metal stents (BMS). Binary angiographic restenosis is lower with DES compared to BMS (odds ratio 0.15, 95% CI 0.08, 0.26, P for heterogeneity = 0.20) and sirolimus eluting stents (SES) have been shown in one study to have a lower binary angiographic restenosis rate compared to paclitaxel eluting stent (PES) (9.4% SES versus 28.6% PES, P=0.020). Stent thrombosis rates are similar for both DES and BMS. Long-term (36 month) outcomes of death, MI and stent thrombosis remained similar between BMS and DES patients. Large, high-quality, prospective strategy trials are needed to provide more information on the validity of treating CTO, on role of DES in CTO and to determine if use of second generation DES could provide even more favorable outcomes.
These data on the initial success in the treatment of coronary CTO need to be balanced against potential risk of complications. Risk of serious and life-threatening complications like coronary perforations and large dissections are more frequent compared to a non-CTO PCI. On the same note, early recognition and ability to promptly deal with these complications are critical to CTO treatment plans.
Substantial familiarity and training prior to attempting CTO are crucial, along with a minimum of 50 CTO procedures a year. From our personal experience and that of many prior CTO experts, a mentoring program along with development of a core group of institutional or regional core group of CTO experts are necessary to achieve high and reproducible success rates with minimal complications.
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