With great interest, I read the manuscript entitled “Three-year Outcomes of A Randomised Multicenter Trial Comparing Revascularization and Optimal Medical Therapy for Chronic Total Coronary Occlusions (EuroCTO)” in EuroIntervention1. They confirmed numerous previous data that chronic total occlusion (CTO) interventions do not improve clinically significant outcomes, myocardial infarction or mortality. However, the authors overstated the benefit of a CTO intervention by stating that CTO percutaneous coronary intervention (PCI) appears to be a safe option for patients with a single remaining significant coronary CTO. The authors completely downplayed numerous trials showing very high complication rates in patients undergoing CTO PCI in comparison to other lesions2,3. We recently published the largest data regarding CTO PCI confirming much higher in-patient mortality and complications in this population4. A weighted total of 259,574 patients underwent CTO PCI. The CTO patients had a 3.17% mortality rate versus 2.57% for non-CTO PCIs (odds ratio [OR] 1.24), which remained significant despite adjusting for numerous baseline and clinical characteristics. Furthermore, patients with CTO were compared with non-CTO PCI, showing much higher rates of myocardial infarction (OR 2.85), coronary perforation (OR 6.01), tamponade (OR 3.36), contrast-induced nephropathy (OR 2.05), procedural bleeding (OR 3.57), and acute postprocedural respiratory failure (OR 2.07). The total postprocedural complications for CTO patients were more than 3 times those of non-CTO patients (OR 3.45). In concordance with our conclusion, Allahwala et al5 agree that CTO PCI should not be performed unless the patient has severe resistant angina and for symptom release only. However, CTO PCI is too often performed without informing the patient that this dangerous procedure will not prolong life. It is time to have a better oversight of interventionalists who perform too many unnecessary PCIs of CTO6.
Acknowledgments
Conflict of interest statement
M.R. Movahed has no conflicts of interest to declare.
References
- 1 Werner GS, Hildick-Smith D, Martin Yuste V, Boudou N, Sianos G, Gelev V, Rumoroso JR, Erglis A, Christiansen EH, Escaned J, Di Mario C, Teruel L, Bufe A, Lauer B, Galassi AR, Louvard Y. Three-year outcomes of A Randomized Multicentre Trial Comparing Revascularization and Optimal Medical Therapy for Chronic Total Coronary Occlusions (EuroCTO). EuroIntervention. 2023;19:571–9. doi: 10.4244/EIJ-D-23-00312. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2 Khan MF, Brilakis ES, Wendel CS, Thai H. Comparison of procedural complications and in-hospital clinical outcomes between patients with successful and failed percutaneous intervention of coronary chronic total occlusions: a meta-analysis of observational studies. Catheter Cardiovasc Interv. 2015;85:781–94. doi: 10.1002/ccd.25712. [DOI] [PubMed] [Google Scholar]
- 3 Khan MF, Wendel CS, Thai HM, Movahed MR. Effects of percutaneous revascularization of chronic total occlusions on clinical outcomes: a meta-analysis comparing successful versus failed percutaneous intervention for chronic total occlusion. Catheter Cardiovasc Interv. 2013;82:95–107. doi: 10.1002/ccd.24863. [DOI] [PubMed] [Google Scholar]
- 4 Nathan A, Hashemzadeh M, Movahed MR. Percutaneous Coronary Intervention of Chronic Total Occlusion Associated with Higher Inpatient Mortality and Complications Compared With Non-CTO Lesions. Am J Med. 2023;136:994–9. doi: 10.1016/j.amjmed.2023.06.004. [DOI] [PubMed] [Google Scholar]
- 5 Allahwala UK, Ward MR, Brieger D, Weaver JC, Bhindi R. Indications for Percutaneous Coronary Intervention (PCI) in Chronic Total Occlusion (CTO): Have We Reached a DECISION or Do We Continue to EXPLORE After EURO-CTO? Heart Lung Circ. 2019;28:1484–9. doi: 10.1016/j.hlc.2019.03.014. [DOI] [PubMed] [Google Scholar]
- 6 Movahed MR. It is time to have better oversite and accountability in performing too many not indicated percutaneous coronary interventions in patients with chronic total occlusions. Int J Cardiol. 2019;278:38–9. doi: 10.1016/j.ijcard.2018.11.122. [DOI] [PubMed] [Google Scholar]