title: Successful recanalization of chronic total occlusions is associated with improved long-term survival.
abstract: OBJECTIVE
  This study investigated the impact of procedural success on mortality following chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in a large cohort of patients in the drug-eluting stent era.
  
  
  BACKGROUND
  Despite advances in expertise and technologies, many patients with CTO are not offered PCI.
  
  
  METHODS
  A total of 6,996 patients underwent elective PCI for stable angina at a single center (2003 to 2010), 836 (11.9%) for CTO. All-cause mortality was obtained to 5 years (median: 3.8 years; interquartile range: 2.0 to 5.4 years) and stratified according to successful chronic total occlusion (sCTO) or unsuccessful chronic total occlusion (uCTO) recanalization. Major adverse cardiac events (MACE) included myocardial infarction (MI), urgent revascularization, stroke, or death.
  
  
  RESULTS
  A total of 582 (69.6%) procedures were successful. Stents were implanted in 97.0% of successful procedures (mean: 2.3 ± 0.1 stents per patient, 73% drug-eluting). Prior revascularization was more frequent among uCTO patients: coronary artery bypass grafting (CABG) (16.5% vs. 7.4%; p < 0.0001), PCI (36.0% vs. 21.2%; p < 0.0001). Baseline characteristics were otherwise similar. Intraprocedural complications, including coronary dissection, were more frequent in unsuccessful cases (20.5% vs. 4.9%; p < 0.0001), but did not affect in-hospital MACE (3% vs. 2.1%; p = NS). All-cause mortality was 17.2% for uCTO and 4.5% for sCTO at 5 years (p < 0.0001). The need for CABG was reduced following sCTO (3.1% vs. 22.1%; p < 0.0001). Multivariate analysis demonstrated that procedural success was independently predictive of mortality (hazard ratio [HR]: 0.32 [95% confidence interval (CI): 0.18 to 0.58]), which persisted when incorporating a propensity score (HR: 0.28 [95% CI: 0.15 to 0.52]).
  
  
  CONCLUSIONS
  Successful CTO PCI is associated with improved survival out to 5 years. Adoption of techniques and technologies to improve procedural success may have an impact on prognosis.
authors.affiliation: Department of Cardiology, Barts and the London NHS Trust, London, United Kingdom.
authors.forename: Daniel A
authors.initials: DA
authors.lastname: Jones
authors.forename: Roshan
authors.initials: R
authors.lastname: Weerackody
authors.forename: Krishnaraj
authors.initials: K
authors.lastname: Rathod
authors.forename: Jonathan
authors.initials: J
authors.lastname: Behar
authors.forename: Sean
authors.initials: S
authors.lastname: Gallagher
authors.forename: Charles J
authors.initials: CJ
authors.lastname: Knight
authors.forename: Akhil
authors.initials: A
authors.lastname: Kapur
authors.forename: Ajay K
authors.initials: AK
authors.lastname: Jain
authors.forename: Martin T
authors.initials: MT
authors.lastname: Rothman
authors.forename: Craig A
authors.initials: CA
authors.lastname: Thompson
authors.forename: Anthony
authors.initials: A
authors.lastname: Mathur
authors.forename: Andrew
authors.initials: A
authors.lastname: Wragg
authors.forename: Elliot J
authors.initials: EJ
authors.lastname: Smith
mesh_terms: D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D016009:Chi-Square Distribution; D002908:Chronic Disease; D017023:Coronary Angiography; D054059:Coronary Occlusion / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D054855:Drug-Eluting Stents; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D008131:London; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009203:Myocardial Infarction / Q000209:etiology / Q000401:mortality; D011237:Predictive Value of Tests; D057216:Propensity Score; D016016:Proportional Hazards Models; D012042:Registries; D018570:Risk Assessment; D012307:Risk Factors; D020521:Stroke / Q000209:etiology / Q000401:mortality; D013997:Time Factors; D016896:Treatment Outcome