DECISION-CTO: Prevailing Questions on CTO Rechanneling

The first and only randomized trial on chronic total occlusion (CTO) revascularization versus optimal medical therapy in stable patients has disappointed interventional cardiologists.

According to Dr. Seung-Jung Park, who presented the study, evidence suggests that optimal medical therapy is a reasonable initial treatment strategy for chronic total occlusion, when compared with angioplasty.

Critics of rechanneling procedures have cited its higher complication rate compared with conventional elective angioplast and the higher amount of materials and level of skill necessary to complete the procedures. In addition, rechanneling is mainly used to alleviate symptoms and not reduce cardiovascular events.

The DECISION-CTO study presented at the American College of Cardiology 2017 Scientific Session represents a study cardiologists have been calling on for years. This trial randomized 834 patients from 19 hospitals in Asia with silent ischemia, stable chronic angina or acute coronary syndrome and chronic total occlusion to either optimal medical therapy or angioplasty.

The trial was designed to demonstrate the noninferiority of optimal medical therapy to angioplasty at 5 years. However, recruiting patients was difficult and the trial was stopped early.

Rechanneling success was 91.1% and, at 3 years, the combined endpoint of all-cause death, infarction, stroke, and repeat revascularization in the intention-to-treat population was similar for patients assigned to either strategy (19.6% vs. 20.6%; p = 0.008 for noninferiority).

There were no differences in any of the individual endpoints, nor among prespecified subgroups, or in quality of life.

The analysis of population according to treatment received is a finding that warrants further study. Patients who underwent successful angioplasty experienced fewer events than those who received medical therapy.

Original title: Drug-Eluting Stent Versus Optimal Medical Therapy in Patients with Coronary Chronic Total Occlusion: DECISION CTO Randomized Trial.

Presenter: Park S-J.

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