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Barriers to adoption of more widespread use of PCI for chronic total occlusions (CTO) may include biases that influence operator and clinician decision-making. It is unknown whether, and to what degree, operators may preferentially perform PCI in non-CTO vessels among patients with CTO, despite evidence of ischemia in the CTO distribution.
We reviewed all cardiac catheterizations at the Massachusetts General Hospital over a 5 year period (2009 – 2013), prior to the establishment of a formal CTO PCI program, in which a CTO was diagnosed and PCI of any vessel was performed (N=532). Clinical variables, procedural results, and the presence of stress imaging data available prior to PCI were assessed by record review. Concordance or discordance between the PCI vessel and the myocardial territory of ischemia on stress imaging was determined jointly by an interventional cardiologist and cardiac imaging specialist.
Of the 532 patients with chronic total coronary occlusions undergoing PCI, 100 patients (19%) underwent PCI of the chronic total occlusion and 432 patients (81%) underwent PCI of a non-CTO lesion. The procedural success rate in of CTO PCI in this cohort was 77%. 247 patients (46%) had stress imaging data available prior to PCI, including 54% of the CTO PCI group and 45% of the non-CTO PCI group. The territory of myocardial ischemia on stress imaging was concordant with the PCI vessel in 91% of the CTO PCI group and 68% of the non-CTO PCI group, a highly statistically significant difference (p=0.0008).
CTO PCI was associated with a significantly higher degree of concordance between vessel treated and territory of ischemia on stress imaging compared with non-CTO PCI, among patients with CTOs on diagnostic angiography. The complexity of CTO procedures may incentivize operators to perform PCI in non-ischemic regions.
CORONARY: Complex and Higher Risk Procedures for Indicated Patients (CHIP)