Outcomes of Chronic Total Occlusions in Coronary Arteries According to Three Therapeutic Strategies: A Meta-analysis with 6985 Patients from 8 Published Observational Studies

Coronary Artery Bypass Grafting versus Percutaneous Coronary Intervention in Patients with Chronic Total Occlusion

OBJECTIVES

 Mechanisms of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) differ as CABG provides surgical collateralization and may prolong life by preventing future myocardial infarctions (MIs). However, evidence for CABG in patients with chronic total occlusion (CTO) has not been fully elucidated and the impact of PCI is discussed controversially.

METHODS

 We performed a meta-analysis of studies comparing outcomes in patients with/without multivessel disease undergoing CABG or PCI for CTO. The primary outcome was long-term all-cause mortality (≥5 years). Secondary outcomes were MIs, repeat revascularization, cardiac mortality, major adverse cardiovascular events, and stroke, as well as short-term mortality (30 days/in-hospital) and stroke. A pooled Kaplan-Meier survival curve after reconstruction analysis was generated. Random-effects models were used.

RESULTS

 Six studies totaling 12,504 patients were included. In the pooled Kaplan-Meier analysis, PCI showed a significantly higher risk of death in the follow-up compared with CABG (hazard ratio [HR]: 2.12, 95% confidence interval [CI]: 1.88-2.38, p < 0.01). During the observation period, PCI was also associated with higher rates of MI (odds ratio [OR]: 2.86, 95% CI: 1.82-4.48, p < 0.01) and more repeat revascularization (OR: 4.88, 95% CI: 1.99-11.91, p = 0.0005). The other outcomes did not show significant differences.

CONCLUSION

 CABG is associated with superior survival to PCI over time in patients with CTO who are eligible for both PCI and CABG. This survival advantage is associated with fewer events of MI and repeat revascularization.

Percutaneous Coronary Intervention versus Coronary Artery Bypass Grafting for Chronic Total Occlusion of Coronary Arteries: A Systematic Review and Meta-Analysis

Introduction

Chronic total occlusion (CTO) of coronary arteries constitutes a substantial clinical challenge and has historically been managed through medical management and coronary artery bypass grafting (CABG). However, with the advancement in interventional technology, the success rate of percutaneous treatment has been significantly improved, and percutaneous coronary intervention (PCI) has emerged as a primary mode of treatment for CTOs, demonstrating remarkable clinical efficacy. The objective of this systematic review and meta-analysis is to evaluate and contrast the outcomes of PCI and CABG in patients with CTO.

Methods and Results

A systematic search was conducted in the databases of PubMed, Embase, and Web of Science. The primary endpoints evaluated in this meta-analysis were the occurrence of major adverse cardiac events (MACE) and all-cause mortality. Secondary endpoints included myocardial infarction (MI), cardiac death, and the need for repeat revascularization. Nine studies, encompassing a total of 8,674 patients, were found to meet the criteria for inclusion and had a mean follow-up duration of 4.3 years. The results of the meta-analysis revealed that compared to CABG, PCI was associated with a lower incidence of all-cause mortality (RR: 0.78, 95% CI: 0.66-0.92; P = 0.003) and cardiac death (RR: 0.55; 95% CI: 0.31-0.96; P < 0.05), but an increased risk of myocardial infarction (MI) (RR: 1.96; 95%CI: 1.07-3.62; P < 0.05) and repeat revascularization (RR: 7.13; 95% CI: 5.69-8.94; P < 0.00001). There was no statistically significant difference in MACE (RR: 1.11; 95% CI: 0.69-1.81; P = 0.66) between the PCI and CABG groups.

Conclusion

In the present meta-analysis comparing PCI and CABG in patients with chronic total occlusion of the coronary arteries, the results indicated that PCI was superior to CABG in reducing all-cause mortality and cardiac death but inferior in decreasing myocardial infarction and repeat revascularization. There was no statistically significant difference in MACE between the two groups.

Endovascular revascularization of multi segment chronically occluded ICA

This case report describes a novel endovascular method for treating chronically occluded internal carotid artery (COICA). The patient is a 55-year-old male with vascular risk factors who presented to an outside institution with right-sided weakness and dysarthria, was diagnosed as having a stroke, and discharged with medical management. The patient's symptoms failed to improve throughout the week prompting him to visit another outside institution, where computed tomography (CT) angiography showed bilateral occlusion of the ICAs at their origins extending intracranially. The patient was then transferred to our hospital, where head CT revealed bilateral acute infarcts predominantly in the left centrum ovale/corona radiata and left temporoparietal region. CT perfusion showed a large area of hypoperfusion in the entire left hemisphere as well as part of the right hemisphere (mismatch volume of 438-526 mL). The patient had significant neurological deficits despite sustained high perfusion pressure, so the following morning, the patient was taken for angiography showing complete occlusion of the left ICA with support mostly from the left external carotid artery (ECA)/ophthalmic collateralization. The microcatheter was able to be advanced to the level of the ophthalmic segment of the left ICA, so the decision was made to proceed with stenting from the left ophthalmic ICA to the cervical ICA. Seven consecutive coronary-carotid stents were placed to essentially reconstruct the left ICA. Post-stenting, the patient was treated with an Integrilin drip and transitioned to Aspirin and Brilinta the following morning. The patient's symptoms markedly improved after the procedure. CT perfusion, as well as diffusion magnetic resonance imaging (MRI), revealed recovery of the patient's penumbra and stability of the existing infarcts despite the delayed nature of revascularization respectively. This is a rarely reported study in literature describing the successful deployment of multiple stents in recreating the ICA from its extracranial to intracranial portion.

Percutaneous coronary intervention provided better long term results than optimal medical therapy alone in patients with chronic total occlusion: A meta-analysis

AIMS

Studies comparing the outcome of percutaneous coronary intervention (PCI) along with optimal medical therapy (OMT) versus OMT alone in treatment of chronic total occlusion (CTO) are limited by observational design, variable follow-up period, diverse clinical outcomes, high drop-out and cross-over rates. This study aims to conduct a meta-analysis of published data of observational as well as randomized studies comparing long term outcomes of PCI+OMT versus OMT alone.

METHODS AND RESULTS

PubMed, Embase and Cochrane databases were systematically reviewed. 15 studies meeting criteria were included in the meta-analysis. The New-castle Ottawa scale was used to appraise the overall quality of the studies. Random-effects model with inverse variance method was undertaken. Major adverse cardiovascular events (MACE) which comprises of cardiac death, myocardial infarction, stroke, and un-planned revascularization were significantly lower in the PCI+OMT group (RR:0.76; 95% CI:0.61 to 0.95; P=<0.00001; I² = 85%). All-cause mortality and cardiac death were significantly lower in the PCI+OMT group (P=<0.00001 in both). Myocardial infarction and stroke rates were lower in the PCI+OMT group, however they did not reach statistical significance (P = 0.24, P = 0.15 respectively). Unplanned revascularizations (of any vessel) were also similar in both the groups (P = 0.78, I² = 88%).

CONCLUSION

PCI of CTO is rewarded with better long term outcome, in terms of MACE, all-cause mortality and cardiac death with similar rates of un-planned revascularization.