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CLINICAL RESEARCH: INTERVENTIONAL CARDIOLOGY

Trends in Outcomes After Percutaneous Coronary Intervention for Chronic Total Occlusions

A 25-Year Experience From the Mayo Clinic

Abhiram Prasad, MD, FRCP, FACC^_*,_*,_*, Charanjit S. Rihal, MD, FACC^_*, Ryan J. Lennon, MS, Heather J. Wiste, BS, Mandeep Singh, MD, FACC^_* and David R. Holmes, Jr, MD, FACC^_*

^_* Division of Cardiovascular Diseases, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
Department of Internal Medicine and Section of Biostatistics, Mayo Clinic and Mayo Foundation, Rochester, Minnesota.

Manuscript received September 20, 2006; revised manuscript received November 21, 2006, accepted December 20, 2006.

^_* Reprint requests and correspondence: Dr. Abhiram Prasad, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905. (Email: prasad.abhiram{at}mayo.edu).

Objectives: The aim of our study was to examine the trends in procedural success, in-hospital, and long-term outcomes after percutaneous coronary intervention (PCI) for chronic total occlusions (CTO) over the last 25 years from a single PCI registry and to examine the impact of drug-eluting stents.

Background: The percutaneous treatment of CTO remains a major challenge. Past studies have used variable definitions of CTO, and there are limited data available from contemporary practice.

Methods: We evaluated the outcomes of 1,262 patients from the Mayo Clinic registry who required PCI for a CTO. The patients were divided into 4 groups according to the time of their intervention: group 1 (percutaneous transluminal coronary angioplasty era), group 2 (early stent era), group 3 (bare-metal stent era), and group 4 (drug-eluting stent era).

Results: Procedural success rates were 51%, 72%, 73%, and 70% (p < 0.001), respectively, in the 4 groups. In-hospital mortality (2%, 1%, 0.4%, and 0%, p = 0.009), emergency coronary artery bypass grafting (15%, 3%, 2%, and 0.7%, p < 0.001), and rates of major adverse cardiac events (8%, 5%, 3%, and 4%, p = 0.052) decreased over time. During follow-up, the combined end point of death, myocardial infarction, or target lesion revascularization, was significantly lower in the 2 most recent cohorts compared with those patients treated before (p = 0.001 for trend). Technical failure to treat the CTO was not an independent predictor of long-term mortality (hazard ratio 1.16 [95% confidence interval 0.90 to 1.5], p = 0.25).

Conclusions: Procedural success rates for CTO have not improved over time in the stent era, highlighting the need to develop new techniques and devices. Compared with the prestent era, in-hospital major adverse cardiac events and 1-year target vessel revascularization rates have declined by approximately 50%.

Abbreviations and Acronyms   BMS = bare-metal stents   CABG = coronary artery bypass grafting   CTO = chronic total occlusion   DES = drug-eluting stents   MACE = major adverse cardiac events   MI = myocardial infarction   PCI = percutaneous coronary intervention   TLR = target lesion revascularization

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