Arnold Remi, Gervasoni Richard, Leclercq Florence
Department of Cardiology, Arnaud de Villeneuve Hospital, 34295 Montpellier, France.
J Clin Med. 2025 Jul 2;14(13):4695. doi: 10.3390/jcm14134695.
Chronic total occlusions (CTOs), defined as complete coronary artery blockages persisting for over three months, are frequently encountered in up to 25% of coronary angiograms. Although percutaneous coronary intervention (PCI) for CTO remains technically challenging, advancements in guidewires, microcatheters, re-entry devices, and intravascular imaging, along with the expertise of specialized operators, have significantly improved procedural success rates, now exceeding 90% in expert centers. While recent evidence, such as the SYNTAX II study, emphasizes the importance of complete revascularization, over half of CTO cases continue to be managed conservatively with optimal medical therapy (OMT), partly due to the limited high-quality randomized evidence supporting revascularization. Observational studies have demonstrated that successful CTO-PCI is associated with improved angina relief, quality of life, left ventricular function, and possibly long-term survival. Extended observational follow-up, such as the Korean and Canadian registries, suggests long-term reductions in cardiac and all-cause mortality with CTO revascularization. However, randomized controlled trials (RCTs) have primarily shown symptomatic benefit, with no consistent reduction in major adverse cardiac events (MACE) or mortality, likely due to limited sample sizes, short follow-up, and treatment crossovers. Various strategies, including the hybrid algorithm, guide CTO interventions by balancing antegrade and retrograde techniques based on lesion complexity. Imaging modalities such as coronary CT angiography and intravascular ultrasound play a pivotal role in planning and optimizing these procedures. Future innovations, such as real-time fusion imaging of CCTA with coronary angiography, may enhance lesion visualization and guidewire navigation. While current guidelines recommend CTO-PCI in selected symptomatic patients with demonstrable ischemia or viable myocardium, the decision should be individualized, incorporating anatomical feasibility, comorbidities, patient preferences, and input from a multidisciplinary Heart Team. Looking ahead, adequately powered RCTs with extended follow-up are essential to determine the long-term clinical impact of CTO-PCI on hard outcomes such as mortality and myocardial infarction.
慢性完全闭塞病变（CTO）定义为冠状动脉完全堵塞持续超过三个月，在高达25%的冠状动脉造影中经常遇到。尽管针对CTO的经皮冠状动脉介入治疗（PCI）在技术上仍然具有挑战性，但导丝、微导管、再入路装置和血管内成像技术的进步，以及专业操作人员的专业知识，显著提高了手术成功率，目前在专家中心已超过90%。虽然近期证据，如SYNTAX II研究，强调了完全血运重建的重要性，但超过一半的CTO病例仍采用最佳药物治疗（OMT）进行保守治疗，部分原因是支持血运重建的高质量随机证据有限。观察性研究表明，成功的CTO-PCI与心绞痛缓解、生活质量改善、左心室功能改善以及可能的长期生存相关。延长的观察性随访，如韩国和加拿大的注册研究，表明CTO血运重建可长期降低心脏和全因死亡率。然而，随机对照试验（RCT）主要显示了症状改善，并未一致降低主要不良心脏事件（MACE）或死亡率，这可能是由于样本量有限、随访时间短以及治疗交叉。包括混合算法在内的各种策略，通过根据病变复杂性平衡正向和逆向技术来指导CTO介入治疗。冠状动脉CT血管造影和血管内超声等成像方式在规划和优化这些手术中起着关键作用。未来的创新，如CCTA与冠状动脉造影的实时融合成像，可能会增强病变可视化和导丝导航。虽然当前指南推荐在有明确缺血或存活心肌的特定有症状患者中进行CTO-PCI，但决策应个体化，综合考虑解剖可行性、合并症、患者偏好以及多学科心脏团队的意见。展望未来，有足够样本量和延长随访的RCT对于确定CTO-PCI对死亡率和心肌梗死等硬终点的长期临床影响至关重要。
