Should Chronic Total Occlusion Be Treated With Coronary Artery Bypass Grafting? Chronic Total Occlusion Should Not Routinely Be Treated With Coronary Artery Bypass Grafting.

Abstract

Chronic total occlusions (CTOs) of the coronary arteries are common. In addition, they are often treated by coronary artery bypass graft (CABG) surgery. The decision to perform CABG for CTOs should be predicated on the demonstration of viability of the subtended myocardium and based on evidence that revascularization will increase the probability of some demonstrably better outcome, whether improved quality of life, prevention of future non-fatal everts or prolongation of life. The literature on surgical revascularization of CTOs is limited, and largely descriptive with only one post-hoc analysis from a randomized trial. There are two small non-randomized studies comparing PCI and to medical therapy. That the outcomes data are so limited affects the ability to justify CABG in this setting. The literature on PCI for CTOs is far more extensive, although there is also limited clinical trial data or comparative effectiveness data concerning choice of therapy for CTOs. Nonetheless, CABG for CTOs can be more easily justified in the setting of multivessel disease where bypass of the CTO is part of an overall strategy of complete revascularization. Thus, CABG for CTOs can be best justified where there is multivessel disease, poorly controlled angina pectoris, and evidence of viability in the subtended zone. While carrying out studies concerning CABG for CTOs will be difficult, a research agenda in this space is clearly needed.