Recanalisation of coronary chronic total occlusions

Percutaneous treatment of coronary chronic total occlusions (CTO) has advanced greatly since its advent in the late 1970s through the development of dedicated wires and microcatheters, the improved skills of highly experienced operators and the adoption of new sophisticated strategies to guide procedural planning. The contemporary procedural success rate is 80-90% with a reduction in complications. Although there has been no improvement in prognosis in randomised trials to date, they, and other controlled registries of thousands of patients, confirm the pivotal role of CTO recanalisation in the treatment of angina and dyspnoea and an improvement in quality of life. Despite this evidence, CTO recanalisation is grossly underutilised. This review reports a detailed overview of the history, indications and treatment strategies for CTO recanalisation and hopes to increase interest among new, and especially young, operators in this demanding, rapidly evolving field of interventional cardiology.

Ventricular Arrhythmias Among Implantable Cardioverter-Defibrillator Recipients for Primary Prevention

Background—

An implantable cardioverter-defibrillator (ICD) is the therapy of choice for primary prevention in patients with ischemia who are at risk for sudden cardiac death (SCD). One third of patients with significant coronary disease have chronic total coronary occlusion (CTO), which is associated with long-term mortality in patients with previous myocardial infarction. However, the impact of CTO on the occurrence of ventricular arrhythmias and long-term mortality in ICD recipients remains unknown.

Methods and Results—

All consecutive patients with coronary artery disease receiving ICD therapy for the prevention of SCD were included in the study. Among other characteristics, the existence of CTO was assessed. During follow-up, the occurrence of appropriate device delivery because of ventricular arrhythmias as well as mortality were noted. A total of 162 patients (mean age, 62±9 years; 93% men) with an ICD were included and followed for a median of 26 months (interquartile range, 12–42). At least 1 CTO was present in 71 (44%) patients. Appropriate device therapy was detected in 18% of the patients during the follow-up. The presence of CTO was associated with higher ventricular arrhythmia and mortality rates (log-rank test, <0.01). Multivariable analysis revealed that CTO was independently associated with appropriate ICD intervention (hazard ratio, 3.5; P =0.003).

Conclusions—

In patients with ischemic heart disease receiving ICDs for primary prevention of SCD, CTO is an independent predictor for the occurrence of ventricular arrhythmias and has an adverse impact on long-term mortality.

[Treatment strategies for chronic total occlusion: current status and outlook]

The present article discusses the current status of treatment strategies for chronic total occlusion (CTO) and the prospects offered by new therapies. The indication for revascularisation recognized in the current European guidelines includes the presence of typical symptoms and evidence of ischemia of over 10% of the total myocardium, while in patients with multiple vascular diseases the aim is complete revascularisation. Although the vast majority of patients with CTO fulfil these criteria, they are currently not receiving interventional treatment as frequently as expected. The reasons often given for this include the low success rates and high recurrence rates. However, both problems have been improved by drug-eluting stents (DES) on the one hand and by wire techniques and strategies on the other, such that results almost comparable with non-occluded coronary lesions can be achieved. While more advanced approaches like retrograde recanalization should be restricted to specialized centres, marked improvements can be achieved even without these special techniques by means of consistent further training and the application of modern techniques. Despite the aggressiveness of these approaches to pass through an occluded artery, the complication rate is not higher than with non-occluded lesions when the specific complications of recanalization are avoided in a careful approach. Further technical improvements are expected with the use of modern imaging techniques such as intravascular ultrasound and high-resolution CT imaging of coronary arteries.

Contemporary success and complication rates of percutaneous coronary intervention for chronic total coronary occlusions: results from the ALKK quality control registry of 2006

AIMS

Despite successful prevention of lesion recurrence by drug-eluting stents (DES), and the advancement in procedural techniques in the treatment of chronic total coronary occlusions (CTO), the number of CTOs treated by percutaneous coronary intervention (PCI) is still low as compared to their prevalence. This study aims to assess the outcome of PCI for CTOs in a contemporary survey of PCI in interventional centres in Germany.

METHODS AND RESULTS

The basis of this analysis is the 2006 quality assessment database of PCI conducted by the ALKK (working group of cardiology centres). Thirty-five centres contributed to this database, representing about 10% of all interventional centres of Germany. From a total of 20,502 patients, 8,882 patients with stable angina were selected. Of these 674 patients (7.6%) underwent PCI for a CTO. Their procedural characteristics and the hospital outcome were compared with patients treated for non-occlusive lesions. As compared to non-occlusive lesions, less patients underwent ad hoc PCI for a CTO. The fluoroscopy time was almost double of that in non-occlusive lesions, and contrast usage was significantly higher. The success rate was 60.1% as compared to 97.3% (p<0.001). Severe intraprocedural and in-hospital complications were similar for CTO and non-CTO lesions. Almost all patients with a CTO received a stent; DES were used in 53.4%, which was higher than the rate in non-CTO lesions (38.9%; p<0.001).

CONCLUSIONS

Although the success rate for PCI in CTOs is still well below that in non-occlusive lesions, this procedure is safe, encouraging its wider application. The low rate of DES use did not reflect the evidence for DES in CTOs.