Percutaneous coronary intervention versus medical therapy for chronic total coronary occlusions: a systematic review and meta-analysis of randomised trials

BACKGROUND: The results of chronic total occlusion percutaneous coronary intervention (CTO-PCI) trials are inconclusive. Therefore, we studied whether CTO-PCI leads to improvement of clinical endpoints and patient symptoms when combining all available randomised data. METHODS AND RESULTS: This meta-analysis was registered in PROSPERO prior to starting. We performed a literature search and identified all randomised trials comparing CTO-PCI to optimal medical therapy alone (OMT). A total of five trials were included, comprising 1790 CTO patients, of whom 964 were randomised to PCI and 826 to OMT. The all-cause mortality was comparable between groups at 1‑year [risk ratio (RR) 1.70, 95% confidence interval (CI) 0.50-5.80, p = 0.40] and at 4‑year follow-up (RR 1.14, 95% CI 0.38-3.40, p = 0.81). There was no difference in the incidence of major adverse cardiac events (MACE) between groups at 1 year (RR 0.69, 95% CI 0.36-1.33, p = 0.27) and at 4 years (RR 0.85, 95% CI 0.60-1.22, p = 0.38). Left ventricular function and volumes at follow-up were comparable between groups. However, the PCI group had fewer target lesion revascularisations (RR 0.28, 95% CI 0.15-0.52, p < 0.001) and was more frequently free of angina at 1‑year follow-up (RR 0.65, 95% CI 0.50-0.84, p = 0.001), although the scores on the subscales of the Seattle Angina Questionnaire were comparable. CONCLUSION: In conclusion, in this meta-analysis of 1790 CTO patients, CTO-PCI did not lead to an improvement in survival or in MACE as reported at long-term follow-up of up to 4 years, or to improvement of left ventricular function. However, CTO-PCI resulted in less angina and fewer target lesion revascularisations compared to OMT.