The Evidence Base for Revascularisation of Chronic Total Occlusions

When patients with ischaemic heart disease are considered for revascularisation the Heart Team’s aim is tochoose a therapy that will provide complete relief of angina for an acceptable procedural risk. Complete functional revascularisationof ischaemic myocardium is thus the goal and for this reason the presence of a chronic total occlusion(CTO) - which remain the most technically challenging lesions to revascularise percutaneously - is the most common reasonfor selecting coronary artery bypass surgery [1]. From the behaviour of Heart Teams it is clear that physicians believethat CTOs are important. Yet when faced with patients with CTOs for whom surgery appears excessive (e.g. nonproximalLAD) or too high risk, there remains a reluctance to undertake CTO PCI, despite significant recent advances inprocedural success and safety and a considerable body of evidence supporting a survival benefit following successfulCTO PCI. This article reviews the relationship between CTOs, symptoms of angina, ischaemia and left ventricular dysfunctionand further explores the evidence relating their treatment to improved quality of life and prognosis in patientswith these features.