Should Chronic Total Occlusion Be Treated With Coronary Artery Bypass Grafting?

Coronary artery chronic total occlusions (CTOs) are an exacerbation of stable coronary artery disease (CAD) with advanced calcification. CTOs are defined as 100% coronary occlusions with Thrombolysis in Myocardial Infarction grade 0 flow persisting for u003e3 months.1 National database registries and large single-center series suggest that in patients with CAD the overall incidence of CTOs may vary from 16% to 19% in Japan2 and 29% to 33% in North America,3 making this a common problem globally. Treatment of CTOs should be considered if associated with symptoms or viable/ischemic myocardial territories. Historically, treatments have been via coronary artery bypass grafting (CABG) or medical therapy.3–9Response by Weintraub and Garratt on p 1817 use of percutaneous coronary intervention (PCI) to treat CTOs (CTO-PCI) against established practice is controversial.10 This controversy is facilitated by the poor evidence available and by lack of clarity in the European and American guidelines for revascularization, including those for patients with stable CAD.11–15 The lack of robust evidence and the unclear guidelines can lead to ill-defined clinical indications determining serious geographical discrepancies in CTO-PCI medical practice. In a recent report from Japan, u003e61% of patients diagnosed with CTOs (19% of all CAD patients) were treated with CTO-PCI.2 This is a significant increase compared with a previous report from North America in which only 6% to 9% of all CTOs (29%–33% of all CAD cases) were treated with CTO-PCI (range, 1%–16% by geographical area/center).3 The report by Yamamoto and coworkers2 suggests widespread use of CTO-PCI in patients with multivessel CAD. This is likely to be at the expense of more established treatments such as CABG. The difference in CTO-PCI practice observed between Japan and North America is not easily explained. Contributing factors may be differences …