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Meta-Analysis of Clinical Outcomes of Patients Who Underwent Percutaneous Coronary Interventions for Chronic Total Occlusions

Published:February 19, 2015DOI:https://doi.org/10.1016/j.amjcard.2015.02.038
      Successful percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs) has been associated with clinical benefit. There are no randomized controlled trials on long-term clinical outcomes after CTO PCI, limiting the available evidence to observational cohort studies. We sought to perform a weighted meta-analysis of the long-term outcomes of successful versus failed CTO PCI. A total of 25 studies, published from 1990 to 2014, with 28,486 patients (29,315 CTO PCI procedures) were included. We analyzed data on mortality, subsequent coronary artery bypass grafting (CABG), myocardial infarction, major adverse cardiac events, angina pectoris, stroke, and target vessel revascularization using random-effects models. Procedural success was 71% (range 51% to 87%). During a weighted mean follow-up of 3.11 years, compared with unsuccessful, successful CTO PCI was associated with lower mortality (odds ratio [OR] 0.52, 95% confidence interval [CI] 0.43 to 0.63), less residual angina (OR 0.38, 95% CI 0.24 to 0.60), lower risk for stroke (OR 0.72, 95% CI 0.60 to 0.88), less need for subsequent coronary artery bypass grafting (OR 0.18, 95% CI 0.14 to 0.22), and lower risk for major adverse cardiac events (0.59, 95% CI 0.44 to 0.79). There was no difference in the incidence of target vessel revascularization (OR 0.66, 95% CI 0.36 to 1.23) or myocardial infarction (OR 0.73, 95% CI 0.52 to 1.03). Outcomes were similar in patients who underwent balloon angioplasty only or stenting with bare metal or drug-eluting stents. Compared with failed procedures, successful CTO PCIs are associated with a lower risk of death, stroke, and coronary artery bypass grafting and less recurrent angina pectoris.
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      References

        • Garcia S.
        • Abdullah S.
        • Banerjee S.
        • Brilakis E.S.
        Chronic total occlusions: patient selection and overview of advanced techniques.
        Curr Cardiol Rep. 2013; 15: 334-341
        • Brilakis E.S.
        Manual of Coronary Chronic Total Occlusion Interventions. A Step-by-Step Approach.
        Elsevier, Waltham2013: 270
        • Patel V.G.
        • Brayton K.M.
        • Tamayo A.
        • Mogabgab O.
        • Michael T.T.
        • Lo N.
        • Alomar M.
        • Shorrock D.
        • Cipher D.
        • Abdullah S.
        • Banerjee S.
        • Brilakis E.S.
        Angiographic success and procedural complications in patients undergoing percutaneous coronary chronic total occlusion interventions: a weighted meta-analysis of 18,061 patients from 65 studies.
        JACC Cardiovasc Interv. 2013; 6: 128-136
        • Christopoulos G.
        • Menon R.V.
        • Karmpaliotis D.
        • Alaswad K.
        • Lombardi W.
        • Grantham A.
        • Patel V.G.
        • Rangan B.V.
        • Kotsia A.P.
        • Lembo N.
        • Kandzari D.
        • Carlson H.
        • Garcia S.
        • Banerjee S.
        • Thompson C.A.
        • Brilakis E.S.
        The efficacy and safety of the “hybrid” approach to coronary chronic total Occlusions: Insights from a contemporary multicenter US registry and comparison with prior studies.
        J Invasive Cardiol. 2014; 26: 427-432
        • Christopoulos G.
        • Menon R.V.
        • Karmpaliotis D.
        • Alaswad K.
        • Lombardi W.
        • Grantham J.A.
        • Michael T.T.
        • Patel V.G.
        • Rangan B.V.
        • Kotsia A.P.
        • Lembo N.
        • Kandzari D.E.
        • Lee J.
        • Kalynych A.
        • Carlson H.
        • Garcia S.
        • Banerjee S.
        • Thompson C.A.
        • Brilakis E.S.
        Application of the “hybrid approach” to chronic total occlusions in patients with previous coronary artery bypass graft surgery (from a Contemporary Multicenter US registry).
        Am J Cardiol. 2014; 113: 1990-1994
        • Christopoulos G.
        • Karmpaliotis D.
        • Alaswad K.
        • Lombardi W.L.
        • Grantham J.A.
        • Rangan B.V.
        • Kotsia A.P.
        • Lembo N.
        • Kandzari D.E.
        • Lee J.
        • Kalynych A.
        • Carlson H.
        • Garcia S.
        • Banerjee S.
        • Thompson C.A.
        • Brilakis E.S.
        The efficacy of “hybrid” percutaneous coronary intervention in chronic total occlusions caused by in-stent restenosis: insights from a US multicenter registry.
        Catheter Cardiovasc Interv. 2014; 84: 646-651
        • Joyal D.
        • Afilalo J.
        • Rinfret S.
        Effectiveness of recanalization of chronic total occlusions: a systematic review and meta-analysis.
        Am Heart J. 2010; 160: 179-187
        • Khan M.F.
        • Wendel C.S.
        • Thai H.M.
        • Movahed M.R.
        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
        • Pancholy S.B.
        • Boruah P.
        • Ahmed I.
        • Kwan T.
        • Patel T.M.
        • Saito S.
        Meta-analysis of effect on mortality of percutaneous recanalization of coronary chronic total occlusions using a stent-based strategy.
        Am J Cardiol. 2013; 111: 521-525
        • Jiang L.
        • Cheng X.S.
        • Yang R.Q.
        • Fan Y.L.
        • Zhan R.
        • Hu L.J.
        A meta-analysis of using a stent-based strategy for chronic total coronary occlusions recanalization: effects of length of follow-up on clinical outcomes.
        Int J Cardiol. 2013; 168: 4941-4945
        • Li R.
        • Yang S.
        • Tang L.
        • Yang Y.
        • Chen H.
        • Guan S.
        • Han W.
        • Liu H.
        • Dai J.
        • Gan Q.
        • Fang W.
        • Qu X.
        Meta-analysis of the effect of percutaneous coronary intervention on chronic total coronary occlusions.
        J Cardiothorac Surg. 2014; 9: 41
        • George S.
        • Cockburn J.
        • Clayton T.C.
        • Ludman P.
        • Cotton J.
        • Spratt J.
        • Redwood S.
        • de Belder M.
        • de Belder A.
        • Hill J.
        • Hoye A.
        • Palmer N.
        • Rathore S.
        • Gershlick A.
        • Di Mario C.
        • Hildick-Smith D.
        • British Cardiovascular Intervention Society, National Institute for Cardiovascular Outcomes Research
        Long-term follow-up of elective chronic total coronary occlusion angioplasty: analysis from the U.K. Central Cardiac Audit Database.
        J Am Coll Cardiol. 2014; 64: 235-243
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • Altman D.G.
        • PRISMA Group
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
        BMJ. 2009; 339: b2535
        • Moher D.
        • Cook D.J.
        • Eastwood S.
        • Olkin I.
        • Rennie D.
        • Stroup D.F.
        Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement. Quality of reporting of meta-analyses.
        Lancet. 1999; 354: 1896-1900
        • Garcia S.
        • Sandoval Y.
        • Roukoz H.
        • Adabag S.
        • Canoniero M.
        • Yannopoulos D.
        • Brilakis E.S.
        Outcomes after complete versus incomplete revascularization of patients with multivessel coronary artery disease: a meta-analysis of 89,883 patients enrolled in randomized clinical trials and observational studies.
        J Am Coll Cardiol. 2013; 62: 1421-1431
        • Nombela-Franco L.
        • Mitroi C.D.
        • Fernandez-Lozano I.
        • Garcia-Touchard A.
        • Toquero J.
        • Castro-Urda V.
        • Fernandez-Diaz J.A.
        • Perez-Pereira E.
        • Beltran-Correas P.
        • Segovia J.
        • Werner G.S.
        • Javier G.
        • Luis A.P.
        Ventricular arrhythmias among implantable cardioverter-defibrillator recipients for primary prevention: impact of chronic total coronary occlusion (VACTO Primary Study).
        Circ Arrhythm Electrophysiol. 2012; 5: 147-154
        • Claessen B.E.
        • van der Schaaf R.J.
        • Verouden N.J.
        • Stegenga N.K.
        • Engstrom A.E.
        • Sjauw K.D.
        • Kikkert W.J.
        • Vis M.M.
        • Baan Jr., J.
        • Koch K.T.
        • de Winter R.J.
        • Tijssen J.G.
        • Piek J.J.
        • Henriques J.P.
        Evaluation of the effect of a concurrent chronic total occlusion on long-term mortality and left ventricular function in patients after primary percutaneous coronary intervention.
        JACC Cardiovasc Interv. 2009; 2: 1128-1134
        • Safley D.M.
        • Koshy S.
        • Grantham J.A.
        • Bybee K.A.
        • House J.A.
        • Kennedy K.F.
        • Rutherford B.D.
        Changes in myocardial ischemic burden following percutaneous coronary intervention of chronic total occlusions.
        Catheter Cardiovasc Interv. 2011; 78: 337-343
        • Danchin N.
        • Angioi M.
        • Cador R.
        • Tricoche O.
        • Dibon O.
        • Juilliere Y.
        • Cuilliere M.
        • Cherrier F.
        Effect of late percutaneous angioplastic recanalization of total coronary artery occlusion on left ventricular remodeling, ejection fraction, and regional wall motion.
        Am J Cardiol. 1996; 78: 729-735
        • Sirnes P.A.
        • Myreng Y.
        • Molstad P.
        • Bonarjee V.
        • Golf S.
        Improvement in left ventricular ejection fraction and wall motion after successful recanalization of chronic coronary occlusions.
        Eur Heart J. 1998; 19: 273-281
        • Chung C.M.
        • Nakamura S.
        • Tanaka K.
        • Tanigawa J.
        • Kitano K.
        • Akiyama T.
        • Matoba Y.
        • Katoh O.
        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. 2003; 60: 368-374
        • Michael T.T.
        • Karmpaliotis D.
        • Brilakis E.S.
        • Abdullah S.M.
        • Kirkland B.L.
        • Mishoe K.L.
        • Lembo N.
        • Kalynych A.
        • Carlson H.
        • Banerjee S.
        • Lombardi W.
        • Kandzari D.E.
        Impact of prior coronary artery bypass graft surgery on chronic total occlusion revascularisation: insights from a multicentre US registry.
        Heart. 2013; 99: 1515-1518
        • Lanka V.
        • Patel V.G.
        • Saeed B.
        • Kotsia A.
        • Christopoulos G.
        • Rangan B.V.
        • Mohammad A.
        • Luna M.
        • Garcia S.
        • Abdullah S.M.
        • Grodin J.
        • Hastings J.L.
        • Banerjee S.
        • Brilakis E.S.
        Outcomes with first- versus second-generation drug-eluting stents in coronary chronic total occlusions (CTOs): a systematic review and meta-analysis.
        J Invasive Cardiol. 2014; 26: 304-310
        • Brilakis E.S.
        • Kotsia A.
        • Luna M.
        • Garcia S.
        • Abdullah S.M.
        • Banerjee S.
        The role of drug-eluting stents for the treatment of coronary chronic total occlusions.
        Expert Rev Cardiovasc Ther. 2013; 11: 1349-1358

      Linked Article

      • Suboptimal Choice of Methodology for Meta-Analysis and Publication Bias Assessment
        American Journal of CardiologyVol. 115Issue 12
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          We read the review article by Christakopoulos et al.1 The authors analyzed an important clinical question in their review article. However, we are perplexed by the poor methodology and presentation of the results. The authors make a very vague statement about publication bias, “Publication bias was assessed through visual inspection of funnel plots (Begg's method) which demonstrated some asymmetry for all-cause mortality, myocardial infarction, angina, CABG and MACE suggestive of possible publication bias” and refer readers to the supplemental material to look for answers.
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