title: Clinical outcomes of multiple chronic total occlusions in coronary arteries according to three therapeutic strategies: Bypass surgery, percutaneous intervention and medication.
abstract: BACKGROUND
  Limited data exist regarding clinical outcomes of multiple chronic total occlusions (CTOs) according to therapeutic strategies, coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), and medical treatment (MT).
  
  
  METHODS
  From March 2003 to February 2012, a total of 2024 patients with at least one CTO were enrolled in retrospective, single-center registry. 393 patients with at least two CTOs were categorized based on the intention-to-treat principle. Propensity-score matching was performed. The primary outcome was major adverse cardiac and cerebral events (MACCE).
  
  
  RESULTS
  Of 393 patients with multiple CTOs, 169 patients (43%) were referred for CABG, 130 (33%) for PCI, and 94 (24%) for MT. Median overall follow-up duration was 46.5 (interquartile range 22.7 to 74.6) months. After propensity-score matching analysis, CABG had lower rates of MACCE when compared with PCI (HR=0.43, 0.21-0.85, P=0.01) and MT (HR=0.10, 0.04-0.27, P<0.01). Rates of repeat revascularization was significantly lower in CABG, compared with PCI (HR=0.05, 0.01-0.40, P<0.01) and MT (HR=0.01, 0.00-0.54, P=0.02). CABG had similar rates of cardiac death compared with PCI group (HR=0.97, 0.37-2.53, P=0.95), but had significantly lower rates of cardiac death compared with MT (HR=0.24, 0.08-0.75, P=0.01).
  
  
  CONCLUSIONS
  For management of multiple CTOs, MT alone was associated with higher incidence of cardiac death and MACCE compared with CABG. PCI was associated with higher incidence of MACCE, as driven by higher repeat revascularization rate. These findings suggest that CABG might be associated with better clinical outcome and considered as the preferred treatment strategy in patients with multiple CTOs.
authors.affiliation: Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University, School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 135-710, Republic of Korea; Division of Cardiology, Department of Medicine, Konkuk University Medical Center, 120-1 Neungdong-ro, Hwayang-dong, Gwangjin-gu, Seoul 143-729, Republic of Korea.
authors.forename: Bum Sung
authors.initials: BS
authors.lastname: Kim
authors.affiliation: Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University, School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 135-710, Republic of Korea.
authors.forename: Jeong Hoon
authors.initials: JH
authors.lastname: Yang
authors.affiliation: Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University, School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 135-710, Republic of Korea; Division of Cardiology, Department of Medicine, Samsung Changwon Hospital, Sungkyunkwan University, School of Medicine, Changwon-Si, Gyeongsangnam-Do, Republic of Korea.
authors.forename: Woo Jin
authors.initials: WJ
authors.lastname: Jang
authors.affiliation: Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University, School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 135-710, Republic of Korea.
authors.forename: Young Bin
authors.initials: YB
authors.lastname: Song
authors.affiliation: Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University, School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 135-710, Republic of Korea.
authors.forename: Joo-Yong
authors.initials: JY
authors.lastname: Hahn
authors.affiliation: Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University, School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 135-710, Republic of Korea.
authors.forename: Jin-Ho
authors.initials: JH
authors.lastname: Choi
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 135-710, Republic of Korea.
authors.forename: Wook Sung
authors.initials: WS
authors.lastname: Kim
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 135-710, Republic of Korea.
authors.forename: Young Tak
authors.initials: YT
authors.lastname: Lee
authors.affiliation: Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University, School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 135-710, Republic of Korea.
authors.forename: Hyeon-Cheol
authors.initials: HC
authors.lastname: Gwon
authors.affiliation: Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University, School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 135-710, Republic of Korea.
authors.forename: Sang Hoon
authors.initials: SH
authors.lastname: Lee
authors.affiliation: Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University, School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 135-710, Republic of Korea. Electronic address: sh1214.choi@samsung.com.
authors.forename: Seung-Hyuk
authors.initials: SH
authors.lastname: Choi
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use*; D000368:Aged; D000369:Aged, 80 and over; D001241:Aspirin / Q000627:therapeutic use; D000077144:Clopidogrel; D001026:Coronary Artery Bypass; D054059:Coronary Occlusion / Q000188:drug therapy / Q000601:surgery / Q000628:therapy*; D003331:Coronary Vessels / Q000473:pathology; D003643:Death; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000209:etiology; D062645:Percutaneous Coronary Intervention; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use*; D012042:Registries; D012189:Retrospective Studies; D012307:Risk Factors; D020521:Stroke / Q000209:etiology; D013988:Ticlopidine / Q000031:analogs & derivatives / Q000627:therapeutic use; D016896:Treatment Outcome
chemical_list: D000319:Adrenergic beta-Antagonists; D010975:Platelet Aggregation Inhibitors; D000077144:Clopidogrel; D013988:Ticlopidine; D001241:Aspirin
keywords: Chronic total occlusion; Coronary artery bypass graft; Medication therapy; Percutaneous coronary intervention