Recanalization of isolated chronic total occlusions in patients with stable angina Milosz Jaguszewski a, b, ⁎ , 1 , Radoslaw Targonski a, 1 , Marcin Fijalkowski a, 1 , Emilia Masiewicz a , Witold Dubaniewicz a , Christian Templin b , Andrzej Koprowski a , Dariusz Ciecwierz a , Brahmajee K. Nallamothu c , Andrzej Rynkiewicz a a First Department of Cardiology, Medical University of Gdansk, Gdansk, Poland b Department of Cardiology, Cardiovascular Center, University Hospital Zuerich, Switzerland c Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA abstract article info Article history: Received 4 January 2012 Received in revised form 2 April 2012 Accepted 14 April 2012 Available online 9 May 2012 Keywords: Chronic total occlusion Recanalization Coronary intervention Single-vessel disease Background: Despite procedural advances, recanalization of chronic total occlusions (CTOs) with percutane- ous coronary intervention (PCI) remains controversial, particularly given that its long-term benefits are unclear. We assessed the association between successful PCI and symptom improvement as well as outcomes in patients with CTO and stable angina. Methods: We performed a retrospective study of 386 consecutive patients undergoing attempted PCI of an isolated CTO (i.e., no other angiographically-significant disease was present). We analyzed prospectively the change in Canadian Cardiovascular Society (CCS) classification system and occurrence of major adverse cardiovascular events (death, myocardial infarction or target vessel revascularization), after stratifying pa- tients by procedural success. To understand which patients might benefit most from attempted PCI, multivar- iable models were constructed to predict: likelihood of successful PCI and symptom improvement, defined as resolution of angina or improvement of ≥2 CCS classes. Results: A total of 247 (64%) patients had successful PCI. Greater symptom improvement was noted after suc- cessful PCI at both 6 months (79.8% versus 34.5% with resolution of angina or improvement of ≥2 CCS classes, p b 0.01) and 24 months (71.7% and 20.9%, respectively, p b 0.01). No differences were noted in MACE (11.3% vs. 10.0% at 6 months, p=0.70; and 18.6% vs. 19.4% at 24 months, p=0.84). Multivariable analysis identified sev- eral factors associated with successful PCI, but not predictive of symptom improvement. In conclusion, success- ful PCI of an isolated CTO improves symptom burden, but is not associated with MACE at 6 or 24 months. Conclusions: Several factors are associated with successful PCI, but identifying those most likely to have symp- tom improvement remains challenging. © 2012 Elsevier Ireland Ltd. All rights reserved. 1. Introduction Recanalization of chronic total occlusions (CTOs) accounts for 10% of all percutaneous coronary interventions (PCIs) in patients with sta- ble angina [1–3]. Despite ongoing procedural advances in PCI tech- niques, however, treatment of these lesions remains a challenge. PCI in CTOs is associated with more frequent complications, including vessel perforation and death [4,5]. There are also limited data on the long-term benefits of recanalization in CTOs in regard to symptom improvement. As such, it is critical for clinicians to balance the risks and benefits of PCI in CTOs when making therapeutic decisions. Surprisingly, several limitations in the current literature exist when assessing the benefits of treating CTOs with PCI. One prominent concern has been the inclusion of patients with multi- vessel disease as well as “isolated” CTO in most prior studies, which limits the ability to determine if treatment benefits resulted from revascularization of the CTO or diminished ischemia in other territories. In this context, we performed the current study to exam- ine the association between successful PCI and symptom improve- ment as well as major adverse cardiovascular events (MACE) among patients with an isolated CTO and stable angina. Further- more, we tried to identify clinical factors that predicted successful PCI and symptom improvement. 2. Methods 2.1. Study population, variables and technique We performed a retrospective study of all consecutive patients who underwent an attempted antegrade recanalization of an isolated CTO at the I Department of Cardiol- ogy, Medical University of Gdansk, Poland between 2005 and 2007. Inclusion and ex- clusion criteria are depicted in the Appendix table, and the flow of patients recruited for the study cohort is shown in the Appendix figure. Most patients were excluded International Journal of Cardiology 167 (2013) 1542–1546 ⁎ Corresponding author at: Department of Cardiology, Cardiovascular Center, Uni- versity Hospital Zurich, 8091 Zurich, Switzerland. Tel.: + 41 44 255 11 11; fax: + 41 44 255 44 01. E-mail address: milosz.jaguszewski@usz.ch (M. Jaguszewski). 1 These authors contributed equally to this work and are shared first authors. 0167-5273/$ – see front matter © 2012 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2012.04.097 Contents lists available at SciVerse ScienceDirect International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard