CORONARY ARTERY DISEASE Original Studies Use of Drug-Eluting Stents for Chronic Total Occlusions: A Systematic Review and Meta-analysis Bilal Saeed, 1 MD, David E. Kandzari, 2 MD, Pierfrancesco Agostoni, 3 MD, PhD, William L. Lombardi, 4 MD, Bavana V. Rangan, 5 BDS, MPH, Subhash Banerjee, 5 MD, and Emmanouil S. Brilakis, 5 * MD, PhD Aim: To perform a systematic review and meta-analysis of studies reporting outcomes after drug-eluting stent (DES) implantation in chronic total occlusions (CTOs). Methods: A review of publications and online databases in January 2010 retrieved 17 published studies that reported outcomes after DES implantation in CTOs: eight uncontrolled studies, seven non- randomized comparative studies with bare-metal stents (BMS), one post-hoc analysis of a randomized trial, and one randomized trial. Data were pooled using random-effects meta-analysis models. Results: All published studies evaluated sirolimus- or paclitaxel- eluting stents. All studies reporting comparative angiographic outcomes revealed less binary angiographic restenosis with DES implantation compared to BMS (odds ratio: 0.15, 95% CI: 0.08, 0.26). Over a mean follow-up period of 18.9 6 16.5 months, the cumu- lative incidence of death, myocardial infarction, or stent thrombosis was similar between DES and BMS in all studies. Target lesion revascularization (odds ratio: 0.13, 95% CI: 0.06, 0.26) and target vessel revascularization (odds ratio 0.18, 95% CI: 0.11, 0.31) at 6–12 months were consistently lower among DES-treated patients. Similar patterns of safety and efficacy event rates were also observed in studies reporting >12 month outcomes. Conclusions: Compared with BMS, treatment of chronic total coronary occlusions with DES is associated with significant reductions in angiographic and clinical restenosis with similar safety. The consistency and magnitude of treatment effect across both indi- vidual trials and the pooled analysis establish DES as the preferred therapy for percuta- neous revascularization of CTOs. V C 2010 Wiley-Liss, Inc. Key words: chronic total occlusions; drug-eluting stents; bare-metal stents 1 University of Toledo, Toledo, Ohio 2 Scripps Clinic, La Jolla, California 3 University Medical Center Utrecht, Utrecht, The Netherlands 4 St. Joseph’s Hospital, Bellingham, Washington 5 VA North Texas Healthcare System and University of Texas Southwestern Medical Center at Dallas, Dallas, Texas Conflict of Interest: Dr. Saeed: None. Dr. Kandzari: Research/grant support and consulting honoraria: Abbott Vascular, Cordis Corporation, Medtronic CardioVascular. Dr. Agostoni: Consultant for Genae associates NV. Dr. Lombardi: Consultant for Abbott Vascular (also serves on the medical advisory board), Bridgepoint Medical Systems, and Med- tronic; speaker for Abbott Vascular, Medtronic, and Cordis. Dr. Rangan: None. Dr. Banerjee: Speaker honoraria from St. Jude Medical, Med- tronic, and Johnson & Johnson and research support from Boston Scientific and The Medicines Company. Dr. Brilakis: Research funding from the Department of Veterans Affairs. Speaker honoraria from St Jude Medical; consulting fees from Medicure; research support from Abbott Vascular; salary sup- port from Medtronic (spouse). *Correspondence to: Emmanouil S. Brilakis, MD, PhD, VA North Texas Health Care System, The University of Texas Southwestern Medical Center at Dallas, Division of Cardiology (111A), 4500 S. Lancaster Rd, Dallas, TX 75216. E-mail: esbrilakis@yahoo.com Received 27 May 2010; Revision accepted 28 May 2010 DOI 10.1002/ccd.22690 Published online 13 July 2010 in Wiley Online Library (wileyonlinelibrary.com) V C 2010 Wiley-Liss, Inc. Catheterization and Cardiovascular Interventions 77:315–332 (2011)