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Chronic total coronary occlusions in patients with stable angina pectoris: impact on therapy and outcome in present day clinical practice

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Abstract

Background

Chronic total coronary occlusions (CTOs) represent a subgroup of coronary lesions with a low procedural success and high recurrence rate. However, there is evidence for a prognostic benefit of revascularizing a CTO.

Objective

This study assessed the prevalence of CTOs among patients with stable angina pectoris and its impact on therapeutic strategies.

Methods

Between 2001 and 2003, a survey was conducted in 64 sites to analyze the outcome of the first diagnostic angiography in patients presenting with stable angina pectoris (STAR registry). The clinical characteristics, initial angiographic findings, therapeutic strategy and outcome within the first year were analyzed.

Results

A total of 2,002 patients were entered into the registry. One-third had at least one CTO. At 1 year, the mortality in patients with a CTO was significantly higher than in those without a CTO (5.5 vs. 3.1%; P = 0.009). This excess mortality was related to a higher prevalence of confounding factors in patients with a CTO such as diabetes and more severe LV dysfunction. Patients with a CTO were more likely to undergo surgery or being treated medically, whereas patients without a CTO were more likely to undergo PCI. If a CTO was treated by PCI the periprocedural and long-term outcome was similar to those with PCI for a non-occlusive lesion. However, periprocedural MACE was higher for patients treated for a non-occlusive lesion without first treating the CTO.

Conclusions

The prevalence of CTOs in patients with stable angina pectoris is high, and it influences the clinical outcome within the first year. The therapeutic strategy is influenced towards a rather conservative approach and lower rates of interventional therapy.

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References

  1. Abbott JD, Kip KE, Vlachos HA, Sawhney N, Srinivas VS, Jacobs AK, Holmes DR, Williams DO (2006) Recent trends in the percutaneous treatment of chronic total coronary occlusions. Am J Cardiol 97:1691–1696

    Article  PubMed  Google Scholar 

  2. Baks T, van Geuns RJ, Duncker DJ, Cademartiri F, Mollet NR, Krestin GP, Serruys PW, de Feyter PJ (2006) Prediction of left ventricular function after drug-eluting stent implantation for chronic total coronary occlusions. J Am Coll Cardiol 47:721–725

    Article  CAS  PubMed  Google Scholar 

  3. Bell MR, Berger PB, Menke KK, Holmes DR Jr (1992) Balloon angioplasty of chronic total coronary artery occlusions: what does it cost in radiation exposure, time, and materials? Cathet Cardiovasc Diagn 25:10–15

    Article  CAS  PubMed  Google Scholar 

  4. Boden WE, O’Rourke RA, Teo KK, Hartigan PM, Maron DJ, Kostuk WJ, Knudtson M, Dada M, Casperson P, Harris CL, Chaitman BR, Shaw L, Gosselin G, Nawaz S, Title LM, Gau G, Blaustein AS, Booth DC, Bates ER, Spertus JA, Berman DS, Mancini GB, Weintraub WS (2007) Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med 356:1503–1516

    Article  CAS  PubMed  Google Scholar 

  5. 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 95:1088–1091

    Article  PubMed  Google Scholar 

  6. Chung CM, Nakamura S, Tanaka K, Tanigawa J, Kitano K, Akiyama T, Matoba Y, Katoh O (2003) Effect of recanalization of chronic total occlusions on global and regional left ventricular function in patients with or without previous myocardial infarction. Catheter Cardiovasc Interv 60:368–374

    Article  PubMed  Google Scholar 

  7. Danchin N, Angioi M, Cador R, Tricoche O, Dibon O, Juilliere Y, Cuilliere M, Cherrier F (1996) Effect of late percutaneous angioplastic recanalization of total coronary artery occlusion on left ventricular remodeling, ejection fraction, and regional wall motion. Am J Cardiol 78:729–735

    Article  CAS  PubMed  Google Scholar 

  8. Delacretaz E, Meier B (1997) Therapeutic strategy with total coronary artery occlusions. Am J Cardiol 79:185–187

    Article  CAS  PubMed  Google Scholar 

  9. Di Mario C, Werner GS, Sianos G, Galassi AR, Buettner J, Dudek D, Chevalier B, Lefevre T, Schofer J, Koolen JJ, Sievert H, Reimers B, Fajadet J, Colombo A, Gershlick AH, Serruys PW, Reifart N (2007) European perspective in the recanalisation of chronic total occlusions (CTO): consensus document from the EuroCTO Club. EuroIntervention 3:30–43

    PubMed  Google Scholar 

  10. Dzavik V, Carere RG, Mancini GB, Cohen EA, Catellier D, Anderson TE, Barbeau G, Lazzam C, Title LM, Berger PB, Labinaz M, Teo KK, Buller CE (2001) Predictors of improvement in left ventricular function after percutaneous revascularization of occluded coronary arteries: a report from the Total Occlusion Study of Canada (TOSCA). Am Heart J 142:301–308

    Article  CAS  PubMed  Google Scholar 

  11. Ge L, Iakovou I, Cosgrave J, Chieffo A, Montorfano M, Michev I, Airoldi F, Carlino M, Melzi G, Sangiorgi GM, Corvaja N, Colombo A (2005) Immediate and mid-term outcomes of sirolimus-eluting stent implantation for chronic total occlusions. Eur Heart J 26:1056–1062

    Article  CAS  PubMed  Google Scholar 

  12. Hannan EL, Racz M, Holmes DR, King SB 3rd, Walford G, Ambrose JA, Sharma S, Katz S, Clark LT, Jones RH (2006) Impact of completeness of percutaneous coronary intervention revascularization on long-term outcomes in the stent era. Circulation 113:2406–2412

    Article  PubMed  Google Scholar 

  13. Hochman JS, Lamas GA, Buller CE, Dzavik V, Reynolds HR, Abramsky SJ, Forman S, Ruzyllo W, Maggioni AP, White H, Sadowski Z, Carvalho AC, Rankin JM, Renkin JP, Steg PG, Mascette AM, Sopko G, Pfisterer ME, Leor J, Fridrich V, Mark DB, Knatterud GL (2006) Coronary intervention for persistent occlusion after myocardial infarction. N Engl J Med 355:2395–2407

    Article  CAS  PubMed  Google Scholar 

  14. Hoye A, Tanabe K, Lemos PA, Aoki J, Saia F, Arampatzis C, Degertekin M, Hofma SH, Sianos G, McFadden E, van der Giessen WJ, Smits PC, de Feyter PJ, van Domburg RT, Serruys PW (2004) Significant reduction in restenosis after the use of sirolimus-eluting stents in the treatment of chronic total occlusions. J Am Coll Cardiol 43:1954–1958

    Article  CAS  PubMed  Google Scholar 

  15. Hoye A, van Domburg RT, Sonnenschein K, Serruys PW (2005) Percutaneous coronary intervention for chronic total occlusions: the Thoraxcenter experience 1992–2002. Eur Heart J 26:2630–2636

    Article  PubMed  Google Scholar 

  16. Ito S, Suzuki T, Ito T, Katoh O, Ojio S, Sato H, Ehara M, Kawase Y, Myoishi M, Kurokawa R, Ishihara Y, Suzuki Y, Sato K, Toyama J, Fukutomi T, Itoh M (2004) Novel technique using intravascular ultrasound-guided guidewire cross in coronary intervention for uncrossable chronic total occlusions. Circ J 68:1088–1092

    Article  PubMed  Google Scholar 

  17. Kahn JK (1993) Angiographic suitability for catheter revascularization of total coronary occlusions in patients from a community hospital setting. Am Heart J 126:561–564

    Article  CAS  PubMed  Google Scholar 

  18. Knaapen P, Lubberink M (2008) Cardiac positron emission tomography: myocardial perfusion and metabolism in clinical practice. Clin Res Cardiol

  19. Melchior JP, Doriot PA, Chatelain P, Meier B, Urban P, Finci L, Rutishauser W (1987) Improvement of left ventricular contraction and relaxation synchronism after recanalization of chronic total coronary occlusion by angioplasty. J Am Coll Cardiol 9:763–768

    Article  CAS  PubMed  Google Scholar 

  20. Moreno R, Conde C, Perez-Vizcayno MJ, Villarreal S, Hernandez-Antolin R, Alfonso F, Banuelos C, Angiolillo DJ, Escaned J, Fernandez-Ortiz A, Macaya C (2006) Prognostic impact of a chronic occlusion in a noninfarct vessel in patients with acute myocardial infarction and multivessel disease undergoing primary percutaneous coronary intervention. J Invasive Cardiol 18:16–19

    PubMed  Google Scholar 

  21. Nakamura S, Muthusamy TS, Bae JH, Cahyadi YH, Udayachalerm W, Tresukosol D (2005) Impact of sirolimus-eluting stent on the outcome of patients with chronic total occlusions. Am J Cardiol 95:161–166

    Article  CAS  PubMed  Google Scholar 

  22. Ochiai M, Ashida K, Araki H, Ogata N, Okabayashi H, Obara C (2005) The latest wire technique for chronic total occlusion. Ital Heart J 6:489–493

    PubMed  Google Scholar 

  23. Prasad A, Rihal CS, Lennon RJ, Wiste HJ, Singh M, Holmes DR Jr (2007) Trends in outcomes after percutaneous coronary intervention for chronic total occlusions: a 25-year experience from the Mayo Clinic. J Am Coll Cardiol 49:1611–1618

    Article  PubMed  Google Scholar 

  24. Saito S, Tanaka S, Hiroe Y, Miyashita Y, Takahashi S, Satake S, Tanaka K (2003) Angioplasty for chronic total occlusion by using tapered-tip guidewires. Catheter Cardiovasc Interv 59:305–311

    Article  PubMed  Google Scholar 

  25. Silber S, Albertsson P, Aviles FF, Camici PG, Colombo A, Hamm C, Jorgensen E, Marco J, Nordrehaug JE, Ruzyllo W, Urban P, Stone GW, Wijns W (2005) Guidelines for percutaneous coronary interventions. The Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology. Eur Heart J 26:804–847

    Article  PubMed  Google Scholar 

  26. Sirnes PA, Myreng Y, Molstad P, Bonarjee V, Golf S (1998) Improvement in left ventricular ejection fraction and wall motion after successful recanalization of chronic coronary occlusions. Eur Heart J 19:273–281

    Article  CAS  PubMed  Google Scholar 

  27. Smith SC Jr, Feldman TE, Hirshfeld JW Jr, Jacobs AK, Kern MJ, King SB 3rd, Morrison DA, O’Neill WW, Schaff HV, Whitlow PL, Williams DO, Antman EM, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Nishimura R, Ornato JP, Page RL, Riegel B (2006) ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention–summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention). Circulation 113:156–175

    Article  PubMed  Google Scholar 

  28. Stone GW, Colombo A, Teirstein PS, Moses JW, Leon MB, Reifart NJ, Mintz GS, Hoye A, Cox DA, Baim DS, Strauss BH, Selmon M, Moussa I, Suzuki T, Tamai H, Katoh O, Mitsudo K, Grube E, Cannon LA, Kandzari DE, Reisman M, Schwartz RS, Bailey S, Dangas G, Mehran R, Abizaid A, Serruys PW (2005) Percutaneous recanalization of chronically occluded coronary arteries: procedural techniques, devices, and results. Catheter Cardiovasc Interv 66:217–236

    Article  PubMed  Google Scholar 

  29. Stone GW, Kandzari DE, Mehran R, Colombo A, Schwartz RS, Bailey S, Moussa I, Teirstein PS, Dangas G, Baim DS, Selmon M, Strauss BH, Tamai H, Suzuki T, Mitsudo K, Katoh O, Cox DA, Hoye A, Mintz GS, Grube E, Cannon LA, Reifart NJ, Reisman M, Abizaid A, Moses JW, Leon MB, Serruys PW (2005) Percutaneous recanalization of chronically occluded coronary arteries: a consensus document: part I. Circulation 112:2364–2372

    Article  PubMed  Google Scholar 

  30. Stone GW, Reifart NJ, Moussa I, Hoye A, Cox DA, Colombo A, Baim DS, Teirstein PS, Strauss BH, Selmon M, Mintz GS, Katoh O, Mitsudo K, Suzuki T, Tamai H, Grube E, Cannon LA, Kandzari DE, Reisman M, Schwartz RS, Bailey S, Dangas G, Mehran R, Abizaid A, Moses JW, Leon MB, Serruys PW (2005) Percutaneous recanalization of chronically occluded coronary arteries: a consensus document: part II. Circulation 112:2530–2537

    Article  PubMed  Google Scholar 

  31. Suero JA, Marso SP, Jones PG, Laster SB, Huber KC, Giorgi LV, Johnson WL, Rutherford BD (2001) Procedural outcomes and long-term survival among patients undergoing percutaneous coronary intervention of a chronic total occlusion in native coronary arteries: a 20-year experience. J Am Coll Cardiol 38:409–414

    Article  CAS  PubMed  Google Scholar 

  32. Surmely JF, Suzuki T (2006) Intravascular ultrasound-guided recanalization of a coronary chronic total occlusion located in a stent implanted subintimally: a case report. J Cardiol 48:95–100

    PubMed  Google Scholar 

  33. Surmely JF, Tsuchikane E, Katoh O, Nishida Y, Nakayama M, Nakamura S, Oida A, Hattori E, Suzuki T (2006) New concept for CTO recanalization using controlled antegrade and retrograde subintimal tracking: the CART technique. J Invasive Cardiol 18:334–338

    PubMed  Google Scholar 

  34. Suttorp MJ, Laarman GJ, Rahel BM, Kelder JC, Bosschaert MA, Kiemeneij F, Ten Berg JM, Bal ET, Rensing BJ, Eefting FD, Mast EG (2006) Primary Stenting of Totally Occluded Native Coronary Arteries II (PRISON II): a randomized comparison of bare metal stent implantation with sirolimus-eluting stent implantation for the treatment of total coronary occlusions. Circulation 114:921–928

    Article  PubMed  Google Scholar 

  35. Tsuchikane E, Katoh O, Shimogami M, Ito T, Ehara M, Sato H, Matsubara T, Suzuki T (2005) First clinical experience of a novel penetration catheter for patients with severe coronary artery stenosis. Catheter Cardiovasc Interv 65:368–373

    Article  PubMed  Google Scholar 

  36. Van Belle E, Blouard P, McFadden EP, Lablanche JM, Bauters C, Bertrand ME (1997) Effects of stenting of recent or chronic coronary occlusions on late vessel patency and left ventricular function. Am J Cardiol 80:1150–1154

    Article  PubMed  Google Scholar 

  37. van der Schaaf RJ, Vis MM, Sjauw KD, Koch KT, Baan J Jr, Tijssen JG, de Winter RJ, Piek JJ, Henriques JP (2006) Impact of multivessel coronary disease on long-term mortality in patients with ST-elevation myocardial infarction is due to the presence of a chronic total occlusion. Am J Cardiol 98:1165–1169

    Article  PubMed  Google Scholar 

  38. Werner GS, Bahrmann P, Mutschke O, Emig U, Betge S, Ferrari M, Figulla HR (2003) Determinants of target vessel failure in chronic total coronary occlusions after stent implantation. The influence of collateral function and coronary hemodynamics. J Am Coll Cardiol 42:219–225

    Article  PubMed  Google Scholar 

  39. Werner GS, Fritzenwanger M, Prochnau D, Schwarz G, Krack A, Ferrari M, Figulla HR (2007) Improvement of the primary success rate of recanalization of chronic total coronary occlusions with the safe-cross system after failed conventional wire attempts. Clin Res Cardiol 96:489–496

    Article  PubMed  Google Scholar 

  40. Werner GS, Krack A, Schwarz G, Prochnau D, Betge S, Figulla HR (2004) Prevention of lesion recurrence in chronic total coronary occlusions by paclitaxel-eluting stents. J Am Coll Cardiol 44:2301–2306

    Article  CAS  PubMed  Google Scholar 

  41. Werner GS, Surber R, Kuethe F, Emig U, Schwarz G, Bahrmann P, Figulla HR (2005) Collaterals and the recovery of left ventricular function after recanalization of a chronic total coronary occlusion. Am Heart J 149:129–137

    Article  PubMed  Google Scholar 

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Conflict of interest statement

No conflict of interest exists.

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Authors and Affiliations

  1. Medizinische Klinik I, Klinikum Darmstadt, Grafenstrasse 9, 64283, Darmstadt, Germany

    Gerald S. Werner

  2. Stiftung Institute for Infarct Research Ludwigshafen at the University of Heidelberg, Ludwigshafen, Germany

    Anselm K. Gitt, Uwe Zeymer, Claus Juenger, Frank Towae, Harm Wienbergen & Jochen Senges

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  1. Gerald S. Werner
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  2. Anselm K. Gitt
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Correspondence to Gerald S. Werner.

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Werner, G.S., Gitt, A.K., Zeymer, U. et al. Chronic total coronary occlusions in patients with stable angina pectoris: impact on therapy and outcome in present day clinical practice. Clin Res Cardiol 98, 435–441 (2009). https://doi.org/10.1007/s00392-009-0013-5

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  • DOI: https://doi.org/10.1007/s00392-009-0013-5

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