Chronic total occlusion percutaneous intervention (CTO-PCI) technique has evolved coincident with improvements in success rate and safety of the procedure. Despite this, many patients are not offered this treatment even after medical therapy fails to alleviate their symptoms. The frequently stated reasons for this include the absence of randomized trial data, excessive costs and the time burden of the procedures. In this article our aim is to dispel the myths surrounding the benefits, costs and time burden of CTO-PCI and suggest that these excuses for not attempting CTO-PCI should be avoided so that patients receive the treatment they need, not simply the treatment their provider or institution prefers.'Why didn't my doctor recommend this 3 years ago?' asked Mr J the day after successful chronic total occlusion (CTO) angioplasty. Mr J had suffered with angina after failure of his saphenous vein graft to the right coronary artery (RCA) left him with a 'well collateralized' CTO 3 years earlier. His local cardiologist placed him on three anti-anginal drugs and told him 'nothing more can be done'. After two visits to the emergency department, two stress tests confirming RCA ischemia, a repeat cardiac catheterization reconfirming the only culprit to be the CTO of the RCA, even a stent placement to the grafted left anterior descending artery (LAD) providing him with no benefit, Mr J's family convinced him to seek a second opinion. Questions similar to this are frequently posed by grateful patients after successful CTOpercutaneous coronary intervention (PCI). The answer is complicated: evidence suggests that patients with CTOs are being treated or not treated based on physician preference and institutional biases, not their needs; many excuses are given for not treating appropriate patients with PCI; the real problem is that physicians have not been taught how to treat them with PCI and achieve high success rates and low complication rates when PCI is deemed appropriate. The problem is worthy of consideration since CTOs are discovered in 18% [1] of patients referred for coronary angiography but account for less than 5% of all angioplasties performed [2] in real world PCI registries.
Physician preference & institutional bias influences CTO-PCI decision-makingThere is evidence that the presence of a CTO drives the decision-making over how to treat a patient with coronary artery disease. In the Bypass Angioplasty Revascularization Investigation (BARI) registry, when non-CTO disease was discovered PCI was performed approximately 35% of the time, while when a CTO was discovered, 10% of patients were treated with PCI and a larger proportion were treated with medical therapy [3].Using the National Cardiovascular Disease Registry's CathPCI Registry we found that operator PCI volume was independently associated with CTO-PCI attempt rate such that low volume operators (<50 PCIs/year) were half as likely as intermediate PCIs/year) or high volume (>200 PCIs/year) operators to attempt a CTO once discovered [4]. In a Canadian regi...
