Update on Percutaneous Management of Chronic Total Occlusion

Management of chronic total occlusions (CTOs) remains a challenge for interventional cardiologists. Despite advances in the design of angioplasty hardware and increased operator experience, percutaneous angioplasty of CTO still is associated with a relatively low primary success rate compared with non-CTO. Although the stent has dramatically improved initial and long-term outcome, the incidence of restenosis and reocclusion continues to be high in patients with excessive lesion length and/or small vessel size. Adjunctive pharmacotherapy, such as platelet glycoprotein IIb/IIIa receptor antagonist, may play an important role in the prevention of early reocclusion as well as late restenosis. Similarly, radiation therapy may be useful in the prevention/treatment of in-stent restenosis. Although observational data have shown a poor long-term survival in patients with CTO, convincing prospective or randomized data are lacking. Future investigations will need to focus on the long-term outcome of patients with CTO referred for angioplasty compared with CABG or medical therapy.