1. The Hidden Cost of Underutilizing PCI for Chronic Total Occlusions
A.J. Conrad Smith, MD
University of Pittsburgh Medical Center

2. AJ Conrad Smith, MD
I have no relevant financial relationships

3. PCI for CTO current status
Present in 18-52% of patients undergoing coronary angiography
The minority are treated with PCI
Lower success rates than nonCTO
Complex , resource and time intense interventions
Perception of increased complications
Stable lesions medical management sufficient
Clinical benefits of PCI of CTO

4. Recognized Benefits of CTO PCI
Symptomatic improvement
Improved left ventricular function
Decrease in the need for CABG
Improved Survival
Excess morbidity from subsequent cardiac events
Opportunity cost of foregoing strategy

5. CTO Prevalence and Treatment
Treatment of Patients with CTOs
N = 1,697
Patients with Coronary Artery Disease
N = 14,439
In the Canadian CTO registry, which involved 3 participating centers, a total of 14,439 patients underwent coronary angiography. Of that, 2,630 patients were found to have at least 1 CTO (18.4%).
In terms of treatment of the CTOs, 44% of patients received medical therapy, that is, ‘no revascularization’. 26% of patients received CABG (88% of those patients had the CTO successfully bypassed). Then 30% of patients had PCI to any vessel in the coronary tree, however only 10% of the PCIs were attempted on the actual CTO with a success rate of 70%.
Fefer et al. JACC 2012.

6. Quality of Life post Treatment for CTO
387 patients with CTO treated with 4 different Strategies
SAQ Physical Limitation
SAQ Changes in anginal Frequency
Wijeysundera et al. Eurointervention 2014;

7. Long Term LV Function Improvement with CTO-PCI Most Significant Improvement with <25% Infarction
Before stent implantation
5 months after revascularization
3 years after stent implantation
This study shows long-term LV function improvement with successful CTO-PCI. Patients with less than 25% infarction had the most dramatic increase in segmental wall thickening which was maintained over time.
Improvements in LV volume maintained at 3 years
Degree of transmurality of scar by MRI
Kirschbaum SW et al. American Journal of Cardiology 2008

8. CABG and TVR after PCI for CTO
Single vessel disease in 35% of successes and 25% of failures in Mehran.
Tamborino et al. Am Heart Journal 2013;165:
Meta analysis of 23 studies showed a 75% reduction in CABG
Khan et al. Cath CVI 2013;82:95-107

9. Successful vs Unsuccessful PCI CTO Outcomes
Mehran et al. JACC Intv 2011;4:

10. Incomplete vs Complete Revascularization
Strongest independent predictorof Incomplete Revaascularization was CTO
(HR 2.70, 95% CI )
Farooq et al JACC 2013;61:

11. Impact of non IRA CTO in ACS
Ischemia may be present in Donor vessel territory despite angiographically moderate lesion
Sachdeva et al. Cath CVI 2013;82:E453-E458
CTO as nonIRA in NSTEMI showed greater 12m mortality than patients with non CTO (RR p =0.047)
Gierlotka et al Int Journal Card 2013;168:
Multivariate analysis of nonIRA CTO in STEMI showed CTO independent predictor of 5 y mortality HR % CI ; p=0.0001)
Tajstra et al Am J Cardiol 2012;109:

12. Impact of nonIRA CTO on STEMI Outcomes
Claessen et al. European Hear Journal 2012;33:

13. Trends in CV Revascularization
Diagnostic Catheterizations
PCI with stents
CABG
PCI alone
Riley et al. Circ Cardiovasc Qual Outcomes 2011;4:
Culler et al. Circulation 2015;131:

14. Contribution Margin for CTO
Karmpaliotis, D et al. Cath CV Int 2013;82:1-8

15. Cost Effectiveness of PCI for CTO
Gada et al. Heart 2012;98:
Decision analysis model informed by literature and practice
FACTOR trial QALY analysis
Successful CTO-PCI vs Unsuccessful=Omt
Cost effectiveness ratio 9505$/QALY
Sensitivity analysis two attempts 14047$/QALY
OMT ->30% to CABG then PCI CTO becomes dominant strategy
Multiple assumptions
limited by poor control group (OMT ≠ failed PCI CTO)
No incorporation of stress tests (high frequency of stress and cath in years leading to PCI for CTO in our experience)

16. Effect of CTO volume on Outcomes
Brilakis et al. JACC Intv 2015;8: al

17. Conclusions
Cost of underutilizing PCI for CTO for our patients (leaving them with significant ischemia) is increased morbidity and mortality for patients
Our ability to better quantify this cost/benefit is limited by lack of RCT vs Medical therapy
The cost of not starting a PCI program in addition to the above is lost patient volume and revenue
Incorporation of additional testing and admissions in OMT patients should be included in future analyses

19. Stress Cath and Hospitalizations
Database of 68 patients cathed for CTO in first year of new program
Prior three years average 1.4 stress tests max 4, 1.6 cardiac catheterizations max 4, hospitalizations 1.1 max 5.

21. Trends from the NCDR Database
Brilakis et al JACC Intv 2015: ;