Patient selection for chronic total occlusion recanalization in a dedicated outpatient clinic

Abstract Background Percutaneous coronary interventions (PCI) for chronic total occlusions (CTO) aim primarily to alleviate ischemic symptoms, supported by limited randomized trials. Patient selection criteria for CTO PCI are not standardized, contributing to variability in clinical practice and study cohorts. Methods A shared decision-making resulted to CTO PCI or optimal medical therapy (OMT) alone at a dedicated outpatient clinic. Study groups were compared based on initial decision (decision for PCI vs OMT alone) and vessel status post-PCI. The primary endpoint was a composite of all-cause death, myocardial infarction, CTO PCI attempt, stroke, unplanned cardiovascular or heart failure hospitalization over two years. Results A total of 201 patients were evaluated, with 51.2% undergoing CTO PCI and 48.8% receiving initial decision for OMT alone. OMT was chosen due to lack of symptoms (36.7%), lack of viability (25.5%), and patient refusal of PCI (9.2%). Patients with residual CTO experienced higher rates of all-cause death (16.1% vs. 4.8%, p=0.025) and cardiovascular death (13.6% vs. 2.4%, p=0.013). Patients with decision for OMT alone had fewer future CTO vessel PCI attempts (2.0% vs 13.7%, p=0.005) compared to those undergoing initial PCI. Discussion: Key findings include: 1) Half of all patients underwent CTO PCI 2) Patients with residual CTOs had higher rates of all-cause and cardiovascular mortality, 3) OMT only was associated with fewer subsequent PCI attempts on the CTO vessel during follow-up. Conclusion A dedicated CTO outpatient clinic facilitates informed decision-making, optimizes patient selection for PCI, and enhances management strategies for conservative patients.Table 1.Selection model Figure 1.Clinical endpoints