Clinical Investigation
Interventional Cardiology
Effectiveness of recanalization of chronic total occlusions: A systematic review and meta-analysis

https://doi.org/10.1016/j.ahj.2010.04.015Get rights and content

Background

Chronic total occlusion (CTO) recanalizations remain extremely challenging procedures. With improvements in technology and techniques, success rates for recanalization of CTO continue to improve. However, the clinical benefits of this practice remain unclear. The aim of the study was to determine the effectiveness of CTO recanalization on clinical outcomes.

Methods

We performed a systematic review and meta-analysis of published studies comparing CTO recanalization to medical management. Data were extracted in duplicate and analyzed by a random effects model.

Results

We did not identify any randomized controlled trials or observational studies comparing CTO recanalization to a planned medical management. We did identify 13 observational studies comparing outcomes after successful vs failed CTO recanalization attempt. These studies encompassed 7,288 patients observed over a weighted average follow-up of 6 years. There were 721 (14.3%) deaths of 5,056 patients after successful CTO recanalization compared to 390 deaths (17.5%) of 2,232 patients after failed CTO recanalization (odds ratio [OR] 0.56, 95% CI 0.43-0.72). Successful recanalization was associated with a significant reduction in subsequent coronary artery bypass graft surgery (CABG) (OR 0.22, 95% CI 0.17-0.27) but not in myocardial infarction (OR 0.74, 95% CI 0.44-1.25) or major adverse cardiac events (OR 0.81, 95% CI 0.55-1.21). In the 6 studies that reported angina status, successful recanalization was associated with a significant reduction in residual/recurrent angina (OR 0.45, 95% CI 0.30-0.67).

Conclusions

In highly selected patients considered for CTO recanalization, successful attempts appear to be associated with an improvement in mortality and with a reduction for the need for CABG as compared to failed recanalization. However, given the observational nature of the reviewed evidence, randomized clinical trials are needed to confirm these findings.

Section snippets

Methods

We performed a systematic review and meta-analysis in accordance with the standards set forth by the Quality of Reporting of Meta-analyses (QUOROM) statement.5 We searched PubMed, EMBASE, Web of Science, and the Cochrane Library (up to January 30, 2009). We used the following keywords: “chronic total occlusion,” “percutaneous coronary intervention,” “angioplasty,” and “stent.” We limited our search to the English and French language. In addition, we hand-searched references of retrieved

Results

We did not identify any randomized controlled trial (RCT) or observational study comparing CTO recanalization to a planned medical management strategy. We identified 13 observational studies comparing successful CTO recanalization to a strategy of medical management as a result of attempted but failed CTO recanalization.6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18Figure 1 shows the flow diagram leading to our article selection. Included studies encompassed 7,288 patients treated between 1979

Discussion

Despite increasing interest in the use of PCI for CTO, we found no randomized or observational studies directly comparing recanalization to medical management. Therefore, the current meta-analysis applies only to clinical outcomes after attempted recanalization. In this selected population, we found that successful CTO recanalization was associated with a 44% reduction in mortality, a 78% reduction in subsequent CABG, and a 55% reduction in residual/recurrent angina. Successful recanalization

Conclusion

In the highly selected population of patients who underwent successful recanalization of a CTO, long-term outcomes appear to be improved. Our findings support the evidence suggesting a survival advantage associated with successful versus failed attempt of CTO recanalization as far as it is possible short of an RCT. However, based on the observational nature of the evidence, randomized control trials comparing recanalization to a planed medical management are needed to confirm these findings.

Acknowledgement

Dr Rinfret is a junior clinician-scientist supported by the Fonds de recherche en santé du Québec (FRSQ).

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