1. The document summarizes multiple meta-analyses of clinical outcomes for patients undergoing percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs). 2. Success rates for CTO PCI are around 77% with major adverse cardiac event rates of around 3.0%. Complication rates are generally low but mortality, major adverse cardiac events, and need for emergency bypass surgery are higher with failed versus successful CTO PCI. 3. Successful CTO PCI is associated with improved ejection fraction and reduction in left ventricular end diastolic volume.

1. EuroCTO Club 2015
Friday, September 18, 2015
Meta-analyses of clinical outcomes
of patients who underwent PCI for
CTO (including complications,
antero / retrograde)
17.19-17.32
Emmanouil S. Brilakis, MD, PhD
Director, Cardiac Catheterization Laboratories
VA North Texas Health Care System
Professor of Medicine, University of Texas
Southwestern Medical School, Dallas, Texas

2. Speaker honoraria/consulting fees:
Abbott Vascular, Asahi, Boston
Scientific, Elsevier, Somahlution, St
Jude Medical, Terumo
Research funding: InfraRedx, Boston
Scientific
Employment (spouse): Medtronic
Grants: VA - CLIN-007-11F
VA CSP#571 – DIVA
Disclosures

3. Search performed: 7 Sep 2015

4. Search performed: 7 Sep 2015

5. 23 publications + 1 identified in
manual review (Lanka et al)
18 publications
6 unrelated
1 retracted
17 publications
Meta-analysis of the meta-analyses!

6. Success +
complications
Success vs
failure
EF/STEMI Stents
CTO meta-analyses

7. Success +
complications
Success vs
failure
EF/STEMI Stents
CTO meta-analyses

8. 77% success
3.0% MACE

9. Frequency of CTO complications
65 studies - 18,061 Patients
Patel V et al – JACC Intv 2013
0.2
0.1 <0.01
2.5
3.1
0.2
2.9
0.3 0.3
0.6 0.4
3.8
<0.01

10. CTO PCI: success + complications
65 studies - 18,061 Patients
Patel V et al – JACC Intv 2013

11. Patel V et al – JACC Intv 2013

12. Relative Risk
Mortality: 2.88
MACE: 2.25
Urgent CABG: 6.67
Tamponade: 5.0

14. El Sabbagh,.., Brilakis. Int J Cardiol 2014;174:243-8
Retrograde CTO PCI: success and
complications meta-analysis
2006 – 4/2013
26 studies - 3,482 pts
60
80
100
Overall success
Retrograde success
83,3
74,5
%
0,7 0,7
1,4
6,9
2 2
5,4
0,5
0,0
1,0
2,0
3,0
4,0
5,0
6,0
7,0
8,0
%
vs 0.2 vs 0.1
vs 0.3
vs <0.01

15. From: Retrograde Recanalization of Chronic Total Occlusions in Europe: Procedural, In-Hospital, and Long-
Term Outcomes From the Multicenter ERCTO Registry
J Am Coll Cardiol. 2015;65(22):2388-2400. doi:10.1016/j.jacc.2015.03.566

16. Success +
complications
Success vs
failure
EF/STEMI Stents
CTO meta-analyses

17. Odds ratio
Mortality: 0.56
CABG: 0.22
Angina: 0.45

23. Forest plot for long-term all-cause mortality with successful vs.
failed CTO PCI.
Christakopoulos G, Christopoulos G, Carlino M, Jeroudi O, Roesle M, Rangan BV, Abdullah S, Grodin J, Kumbhani D, Vo M,
Luna M, Alaswad K, Karmpaliotis D, Rinfret S, Garcia S, Banerjee S, Brilakis ES. Am J Cardiol 2015
25 studies
25,486 pts

24. Odds Ratios of most commonly reported clinical outcomes
based on subgroup.
Outcome Stents
Non-
Stents
DES
Non-
DES
CTO
duration
≥ 3
months
n/N (%)
CTO
duration
≤ 3
months
n/N (%)
Studies
published
before
2008
Studies
published
after 2008
All-cause
Mortality
0.44* 0.50* 0.51* 0.52* 0.47* 0.60* 0.50* 0.54*
MACE 0.45* 0.60* 0.38* 0.60* 0.57* 0.49* 0.60* 0.42*
MI 0.35* 0.95 0.39* 0.94 0.52 0.92 0.89 0.58*
CABG 0.15* 0.23* 0.12* 0.18* 0.16* 0.20* 0.22* 0.14*
25 studies
25,486 pts
Christakopoulos G, Christopoulos G, Carlino M, Jeroudi O, Roesle M, Rangan BV, Abdullah S, Grodin J, Kumbhani D, Vo M,
Luna M, Alaswad K, Karmpaliotis D, Rinfret S, Garcia S, Banerjee S, Brilakis ES. Am J Cardiol 2015

25. Success +
complications
Success vs
failure
EF/STEMI Stents
CTO meta-analyses

27. Hoebers L, Claessen BE, Elias J, Dangas GD, Mehran R, Henriques JPS.
Int J Cardiol 2015;187:90-96
Ejection fraction improvement
LVEF increase: 4.44% (95% CI: 3.52–5.35, p < 0.01)
LVEDV decrease: 6.14 ml/m2 (95% CI: − 9.31 to − 2.97, p < 0.01)

29. O’Connor SA, Garot P, Sanguineti F, Hoebers L, Unterseeh T, Banamer H, Chevalier B,
Hovasse T, Morice MC, Lefevre T, Louvard Y. Am J Cardiol 2015;116:8e14

30. Complete vs. incomplete revascularization
Garcia S, Sandoval Y, Roukoz H, Adabag S, Canoniero M, Yannopoulos D, Brilakis ES.
J Am Coll Cardiol. 2013;62:1421-1431
89,883 Patients
RR = 0.71 [0.65-0.77], p<0.001 .
12,259 out of 89,883
(13%) died during follow
up.
Mortality benefit in
patients treated with
CABG (RR 0.70; 95%
CI:0.61-0.80, p<0.001)
and PCI (RR 0.72, 95%
CI:0.64-0.81, p<0.001.
Mortality benefit did not
vary with definition of
CR.

31. Success +
complications
Success vs
failure
EF/STEMI Stents
CTO meta-analyses

32. Odds ratios
Reocclusion: 3.48
TLR: 2.57
PTCA vs. BMS in CTO PCI

34. Colmenarez, H. J. et al. J Am Coll Cardiol 2010;55:1854-1866
DES vs. BMS in CTO PCI

35. Colmenarez, H. J. et al. J Am Coll Cardiol 2010;55:1854-1866
DES vs. BMS in CTO PCI

36. Odds ratios
Reocclusion: 0.34
TLR: 0.13
TVR: 0.18
Stent thrombosis: 1.20

40. 1st vs 2nd generation DES
Lanka et al. J Invasive Cardiol 2014;26:304-10
Target Vessel Revascularization
Target Lesion Revascularization

41. 1. CTO success rates has been
increasing with low
complication rates
2. If you do PCI you’d better
succeed!
3. CTO PCI ↑ EF
4. CTO in non-culprit STEMI lesion
= bad
5. 2nd gen DES > 1st gen DES >
BMS > PTCA
Conclusions

42. Khan 2013
Jiang 2013
Joyal 2010
Pancholy 2013
All meta-analyses have same conclusion!
RCTs are needed!