Abstract
The impact of surgical or percutaneous coronary revascularization on prognosis in patients with a chronic total occlusion (CTO) remains uncertain. Particularly, whether revascularization of those with robust coronary collaterals improves prognosis is unknown. The objective of this study was to determine the predictors and prognostic impact of revascularization of a CTO, and to determine the clinical impact of robust coronary collaterals. Patients with a CTO diagnosed on coronary angiography between Jul 2010 and Dec 2019 were included in this study. Management strategy of the CTO was defined as percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG) or medical management. The degree of collateral robustness was determined by the Rentrop grading classification. Demographic, angiographic and clinical outcomes were recorded. A total of 954 patients were included in the study, of which 186 (19.5%) patients underwent CTO PCI, 296 (31.0%) patients underwent CABG and 472 (49.5%) patients underwent medical management of the CTO. 166 patients (17.4%) had Rentrop grade zero or one collaterals, 577 (60.5%) patients had Rentrop grade two and 211 (22.1%) had Rentrop grade three collaterals. The independent predictors of medical management of the CTO were older age, greater stenosis in the donor vessel, an emergent indication for angiography, a non-LAD CTO and female sex. The degree of collateral robustness was not associated with long-term mortality, while patients who were revascularized either through CABG or PCI had a significantly lower mortality compared to medical management alone (p < 0.0001). In patients with a CTO, the presence of robust collaterals is not associated with prognosis, while both surgical and percutaneous revascularization is associated with improved prognosis. Further research into the optimal revascularization strategy for a CTO is required.
Similar content being viewed by others
References
Shah PB (2011) Management of coronary chronic total occlusion. Circulation 123(16):1780–1784
Christofferson RD, Lehmann KG, Martin GV, Every N, Caldwell JH, Kapadia SR (2005) Effect of chronic total coronary occlusion on treatment strategy. Am J Cardiol 95(9):1088–1091
Jeroudi OM, Alomar ME, Michael TT, El Sabbagh A, Patel VG, Mogabgab O, Fuh E, Sherbet D, Lo N, Roesle M, Rangan BV, Abdullah SM, Hastings JL, Grodin J, Banerjee S, Brilakis ES (2014) Prevalence and management of coronary chronic total occlusions in a tertiary Veterans Affairs hospital. Catheter Cardiovasc Interv 84(4):637–643
Allahwala UK, Jolly SS, Dzavik V, Cairns JA, Kedev S, Balasubramanian K, Stankovic G, Moreno R, Valettas N, Bertrand O, Lavi S, Velianou JL, Sheth T, Meeks B, Brilakis ES, Bhindi R (2018) The presence of a CTO in a non-infarct-related artery during a STEMI treated with contemporary primary pci is associated with increased rates of early and late cardiovascular morbidity and mortality: the CTO-TOTAL substudy. JACC Cardiovasc Interv 11(7):709–711
Kim BS, Yang JH, Jang WJ, Song YB, Hahn JY, Choi JH, Kim WS, Lee YT, Gwon HC, Lee SH, Choi SH (2015) Clinical outcomes of multiple chronic total occlusions in coronary arteries according to three therapeutic strategies: bypass surgery, percutaneous intervention and medication. Int J Cardiol 197:2–7
Wijeysundera HC, Norris C, Fefer P, Galbraith PD, Knudtson ML, Wolff R, Wright GA, Strauss BH, Ko DT (2014) Relationship between initial treatment strategy and quality of life in patients with coronary chronic total occlusions. EuroIntervention 9(10):1165–1172
Khatri J, Abdallah M, Ellis S (2017) Management of coronary chronic total occlusion. Cleve Clin J Med 84(12 Suppl 3):27–38
Sachdeva R, Agrawal M, Flynn SE, Werner GS, Uretsky BF (2014) The myocardium supplied by a chronic total occlusion is a persistently ischemic zone. Catheter Cardiovasc Interv 83(1):9–16
Kayaert P, Coeman M, Drieghe B, Bennett J, McCutcheon K, Dens J, Ungureanu C, Zivelonghi C, Agostoni P, Bataille Y, de Hemptinne Q, Gevaert S, De Pauw M, Haine S (2020) iFR uncovers profound but mostly reversible ischemia in CTOs and helps to optimize PCI results. Catheter Cardiovasc Interv. https://doi.org/10.1002/ccd.29072
Nombela-Franco L, Iannaccone M, Anguera I, Amat-Santos IJ, Sanchez-Garcia M, Bautista D, Calvelo MN, Di Marco A, Moretti C, Pozzi R, Scaglione M, Canadas V, Sandin-Fuentes M, Arenal A, Bagur R, Perez-Castellano N, Fernandez-Perez C, Gaita F, Macaya C, Escaned J, Fernandez-Lozano I (2017) Impact of chronic total coronary occlusion on recurrence of ventricular arrhythmias in ischemic secondary prevention implantable cardioverter-defibrillator recipients (VACTO secondary study) insights from coronary angiogram and electrogram analysis. JACC Cardiovasc Interv 10(9):879–888
Allahwala UK, Kott K, Bland A, Ward M, Bhindi R (2020) Predictors and prognostic implications of well-matured coronary collateral circulation in patients with a chronic total occlusion (CTO). Int Heart J 61(2):223–230
Allahwala U, Nour D, Bhatia K, Ward M, Lo S, Weaver JC, Bhindi R (2020) Prognostic impact of collaterals in patients with a coronary chronic total occlusion (CTO): a meta-analysis of over 3000 patients. Catheter Cardiovasc Interv. https://doi.org/10.1002/ccd.29348
Allahwala UK, Weaver JC, Nelson GI, Nour D, Ray M, Ciofani JL, Ward M, Figtree G, Hansen P, Bhindi R (2020) Effect of Recruitment of acute coronary collaterals on in-hospital mortality and on left ventricular function in patients presenting with ST elevation myocardial infarction. Am J Cardiol 125(10):1455–1460
Allahwala UK, Nour D, Alsanjari O, Bhatia K, Nagaraja V, Khatri JJ, Cockburn J, Hildick-Smith D, Sakata Y, Ward M, Weaver JC, Bhindi R (2020) Prognostic implications of the rapid recruitment of coronary collaterals during ST elevation myocardial infarction (STEMI): a meta-analysis of over 14,000 patients. J Thromb Thrombolysis. https://doi.org/10.1007/s11239-020-02282-6
Rentrop KP, Cohen M, Blanke H, Phillips RA (1985) Changes in collateral channel filling immediately after controlled coronary artery occlusion by an angioplasty balloon in human subjects. J Am Coll Cardiol 5(3):587–592
Werner GS, Ferrari M, Heinke S, Kuethe F, Surber R, Richartz BM, Figulla HR (2003) Angiographic assessment of collateral connections in comparison with invasively determined collateral function in chronic coronary occlusions. Circulation 107(15):1972–1977
Guo L, Lv HC, Huang RC (2020) Percutaneous coronary intervention in elderly patients with coronary chronic total occlusions: current evidence and future perspectives. Clin Interv Aging 15:771–781
Zhang HP, Ai H, Zhao Y, Li H, Tang GD, Zheng NX, Sun FC, Liu JH (2018) Effect of chronic total occlusion percutaneous coronary intervention on clinical outcomes in elderly patients. Am J Med Sci 355(2):174–182
Allahwala UK, Brilakis ES, Byrne J, Davies JE, Ward MR, Weaver JC, Bhindi R (2019) Applicability and interpretation of coronary physiology in the setting of a chronic total occlusion. Circ Cardiovasc Interv 12(7):e007813
Vallabhajosyula S, Prasad A, Gulati R, Barsness GW (2019) Contemporary prevalence, trends, and outcomes of coronary chronic total occlusions in acute myocardial infarction with cardiogenic shock. Int J Cardiol Heart Vasc 24:100414
Teng HI, Sung SH, Huang SS, Pan JP, Lin SJ, Chan WL, Lee WL, Lu TM, Wu CH (2018) The impact of successful revascularization of coronary chronic total occlusions on long-term clinical outcomes in patients with non-ST-segment elevation myocardial infarction. J Interv Cardiol 31(3):302–309
Brilakis ES, Banerjee S, Karmpaliotis D, Lombardi WL, Tsai TT, Shunk KA, Kennedy KF, Spertus JA, Holmes DR Jr, Grantham JA (2015) Procedural outcomes of chronic total occlusion percutaneous coronary intervention: a report from the NCDR (National Cardiovascular Data Registry). JACC Cardiovasc Interv 8(2):245–253
Safley DM, House JA, Marso SP, Grantham JA, Rutherford BD (2008) Improvement in survival following successful percutaneous coronary intervention of coronary chronic total occlusions: variability by target vessel. JACC Cardiovasc Interv 1(3):295–302
Yoneda K, Takahashi T, Kishi K (2020) Over ten years follow-up of chronic total coronary occlusion angioplasty. Cardiovasc Revasc Med. https://doi.org/10.1016/j.carrev.2020.10.013
Maas AH, Appelman YE (2010) Gender differences in coronary heart disease. Neth Heart J 18(12):598–602
Wolff R, Fefer P, Knudtson ML, Cheema AN, Galbraith PD, Sparkes JD, Wright GA, Wijeysundera HC, Strauss BH (2016) Gender differences in the prevalence and treatment of coronary chronic total occlusions. Catheter Cardiovasc Interv 87(6):1063–1070
Allahwala UK, Weaver JC, Bhindi R (2020) Spontaneous coronary collateral recruitment in patients with recurrent ST elevation myocardial infarction (STEMI). Heart Vessels 35(3):291–296
Allahwala UK, Khachigian LM, Nour D, Ridiandres A, Billah M, Ward M, Weaver J, Bhindi R (2020) Recruitment and maturation of the coronary collateral circulation: current understanding and perspectives in arteriogenesis. Microvasc Res 132:104058
Allahwala UK, Weaver J, Bhindi R (2019) Animal chronic total occlusion models: a review of the current literature and future goals. Thromb Res 177:83–90
Nombela-Franco L, Iannaccone M, Anguera I, Amat-Santos IJ, Sanchez-Garcia M, Bautista D, Calvelo MN, Di Marco A, Moretti C, Pozzi R, Scaglione M, Canadas V, Sandin-Fuentes M, Arenal A, Bagur R, Perez-Castellano N, Fernandez-Perez C, Gaita F, Macaya C, Escaned J, Fernandez-Lozano I (2017) Impact of chronic total coronary occlusion on recurrence of ventricular arrhythmias in ischemic secondary prevention implantable cardioverter-defibrillator recipients (VACTO secondary study): insights from coronary angiogram and electrogram analysis. JACC Cardiovasc Interv 10(9):879–888
Henriques JP, Hoebers LP, Ramunddal T, Laanmets P, Eriksen E, Bax M, Ioanes D, Suttorp MJ, Strauss BH, Barbato E, Nijveldt R, van Rossum AC, Marques KM, Elias J, van Dongen IM, Claessen BE, Tijssen JG, van der Schaaf RJ, Investigators ET (2016) Percutaneous intervention for concurrent chronic total occlusions in patients with STEMI: the EXPLORE trial. J Am Coll Cardiol 68(15):1622–1632
Werner GS, Martin-Yuste V, Hildick-Smith D, Boudou N, Sianos G, Gelev V, Rumoroso JR, Erglis A, Christiansen EH, Escaned J, di Mario C, Hovasse T, Teruel L, Bufe A, Lauer B, Bogaerts K, Goicolea J, Spratt JC, Gershlick AH, Galassi AR, Louvard Y, investigators Et (2018) A randomized multicentre trial to compare revascularization with optimal medical therapy for the treatment of chronic total coronary occlusions. Eur Heart J 39(26):2484–2493
Lee S-J, Lee PH, Ahn J-M, Park D-W, Yun S-C, Han S, Kang H, Kang S-J, Kim Y-H, Lee CW, Park S-W, Hur SH, Rha S-W, Her S-H, Choi SW, Lee B-K, Lee N-H, Lee J-Y, Cheong S-S, Kim MH, Ahn Y-K, Lim SW, Lee S-G, Hiremath S, Santosa T, Udayachalerm W, Cheng JJ, Cohen DJ, Muramatsu T, Tsuchikane E, Asakura Y, Park S-J (2019) Randomized trial evaluating percutaneous coronary intervention for the treatment of chronic total occlusion. Circulation 139(14):1674–1683
Allahwala UK, Ward MR, Brieger D, Weaver JC, Bhindi R (2019) 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 28(10):1484–1489
Khanra D, Mishra V, Jain B, Soni S, Bahurupi Y, Duggal B, Rathore S, Guha S, Agarwal S, Aggarwal P, Sinha S, Himanshu K (2020) Percutaneous coronary intervention provided better long term results than optimal medical therapy alone in patients with chronic total occlusion: a meta-analysis. Indian Heart J 72(4):225–231
Hori Y, Yoda S, Nakanishi K, Tano A, Suzuki Y, Matsumoto N, Hirayama A (2015) Myocardial ischemic reduction evidenced by gated myocardial perfusion imaging after treatment results in good prognosis in patients with coronary artery disease. J Cardiol 65(4):278–284
Holzhey DM, Jacobs S, Walther T, Mohr FW, Falk V (2010) Is chronic total coronary occlusion a risk factor for long-term outcome after minimally invasive bypass grafting of the left anterior descending artery? Ann Thorac Surg 89(5):1496–1501
Widimsky P, Straka Z, Stros P, Jirasek K, Dvorak J, Votava J, Lisa L, Budesinsky T, Kolesar M, Vanek T, Brucek P (2004) One-year coronary bypass graft patency: a randomized comparison between off-pump and on-pump surgery angiographic results of the PRAGUE-4 trial. Circulation 110(22):3418–3423
Bonow RO, Maurer G, Lee KL, Holly TA, Binkley PF, Desvigne-Nickens P, Drozdz J, Farsky PS, Feldman AM, Doenst T, Michler RE, Berman DS, Nicolau JC, Pellikka PA, Wrobel K, Alotti N, Asch FM, Favaloro LE, She L, Velazquez EJ, Jones RH, Panza JA, Investigators ST (2011) Myocardial viability and survival in ischemic left ventricular dysfunction. N Engl J Med 364(17):1617–1625
Sun D, Wang J, Tian Y, Narsinh K, Wang H, Li C, Ma X, Wang Y, Wang D, Li C, Wu JC, Tian J, Cao F (2012) Multimodality imaging evaluation of functional and clinical benefits of percutaneous coronary intervention in patients with chronic total occlusion lesion. Theranostics 2(8):788–800
Allahwala UK, Brilakis ES, Kiat H, Ayesa S, Nour D, Ward M, Lo S, Weaver JC, Bhindi R (2020) The indications and utility of adjunctive imaging modalities for chronic total occlusion (CTO) intervention. J Nucl Cardiol. https://doi.org/10.1007/s12350-020-02381-0
Funding
UKA has received an unconditional research grant from Heart Research Australia. RB has received an unconditional future leaders fellowship from the Heart Foundation.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflicts of interest
UKA has received an unconditional research grant from Heart Research Australia. RB has received an unconditional future leaders fellowship from the Heart Foundation.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Allahwala, U.K., Kiat, H., Ekmejian, A. et al. Both surgical and percutaneous revascularization improve prognosis in patients with a coronary chronic total occlusion (CTO) irrespective of collateral robustness. Heart Vessels 36, 1653–1660 (2021). https://doi.org/10.1007/s00380-021-01859-2
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00380-021-01859-2