Effects of percutaneous revascularization of chronic total occlusions on clinical outcomes: a meta-analysis comparing successful versus failed percutaneous intervention for chronic total occlusion

Background: Chronic total occlusions (CTOs) represent the most complex and challenging coronary lesions for percutaneous coronary intervention (PCI). PCI for a CTO is a high-risk procedure and the long-term benefits of a successful percutaneous CTO recanalization over the medical management (as a result of failed PCI) are not clear, as the studies have shown conflicting results in the past. The goal of this analysis was to clarify this issue by performing a meta-analysis of the available literature.

Methods: Using major electronic databases, we searched for studies (randomized or observational) comparing death, major adverse cardiovascular events (MACE), myocardial infarction (MI), and target vessel revascularization (TVR) between patients who underwent PCI recanalization of CTOs versus those treated with medical management as a result of failed PCI attempts.

Results: We identified 23 observational studies comparing the desired clinical parameters between patients with successful CTO recanalization and those managed conservatively as a result of attempted but failed PCI. The total number of patients observed in all of the studies was 12,970 and the mean time of follow up was 3.7 ± 2.1 years. Our results indicated that successful recanalization of a CTO results in improved all-cause mortality (relative risk [RR] of 0.54, 95% confidence interval [CI] (0.45-0.65), P-value < 0.001), lower rates of MACE (RR of 0.70, 95% CI 0.60-0.83, P-value < 0.001) and reduced needs for subsequent bypass surgery (RR of 0.25, 95% CI (0.21-0.30), P-value < 0.001). The difference in long-term mortality remained statistically significant even after the adjustment for procedure related complications and in-hospital deaths.

Conclusion: As compared to conservative management (as a result of failed intervention), successful PCI recanalization of a CTO appears to be associated with improved long-term clinical outcomes; however, randomized controlled trials (RCTs) are needed to further confirm these results.