Avoid Routine PCI for Chronic Total Occlusions in Symptomatic CAD: REVASC Published

September 13, 2018

Opening up chronic total occlusions (CTO) routinely during percutaneous coronary intervention (PCI) does not improve myocardial function, locally or globally, compared with discretionary PCI that specifically avoids CTOs, suggests a study of patients sent to the cath lab based on symptoms or testing positive for ischemia.

Functional improvements in heart muscle regions served by the CTO vessels, whether testing as viable or not, were similar at 6 months in patients assigned to either of the two PCI strategies. That primary endpoint was defined by differences in segmental wall thickness (SWT) between systole and diastole by cardiac magnetic resonance (CMR) imaging. 

Broader measures of left ventricular (LV) function were similarly better after the procedures in both groups of patients, all of whom were receiving optimal medical therapy in the single-center, 205-patient REVASC trial.

"Contrary to our expectations, REVASC failed to show a difference in SWT in the myocardium supplied by the CTO artery," Kambis Mashayekhi, MD, University Heart Center Freiburg, Bad Krozingen, Germany, told theheart.org | Medscape Cardiology by email.

"One reason might have been that even without CTO-PCI, we saw recovery of SWT in the CTO territory after PCI of other relevant lesions," he said. That is, revascularization beyond the target lesion in the non-CTO-PCI group often restored some flow to myocardium under the CTO. And that, he said, might have contributed to the recovery of hibernating myocardium under the untreated CTO, making it hard to show a difference between the two groups.

The findings, published September 12 in JACC: Cardiovascular Interventions with Mashayekhi as lead author, are essentially the same as those presented about 11 months ago at TCT 2017 and covered by theheart.org | Medscape Cardiology  at the time.

Given the study's limitations, an accompanying editorial notes, "it does not give the final answer to the question of improvement in ventricular function after CTO PCI." That, writes Wissam Jaber, MD, Emory University, Atlanta, Georgia, "will require a randomized trial in patients with low LVEF and documented viability and/or large area of ischemia in the CTO territory."

Ideally, such a trial would also include "patients with left anterior descending or combination right coronary and circumflex artery occlusions, preferably treated by high volume operators with proven high success/low complication rates," he writes.

"Until such a trial is performed, which at this point seems quite unlikely, the interventional community should not be treating CTO with the sole indication of improving LV function or reducing major adverse events," he concludes. "As of 2018, CTO PCI should be performed only in patients with viable myocardium who continue to have symptoms on medical management, after other ischemic non-CTO segments have been treated, and with the sole goal of symptom relief."

Of the 101 patients assigned to the CTO PCI group and the 104 to the no-CTO-PCI group, 184 total were available for assessment of the primary endpoint at 6 months.

Table. Myocardial Functional Outcomes, Change From Baseline to 6 Months in REVASC

Endpoints OMT ± Non-CTO PCI (n = 92) OMT + CTO PCI (n = 92) P Value
SWT change in CTO territories (%)a 6.0 4.1 0.71
SWT change in viable CTO territories (%) 10.0 5.9 0.51
LVEF change (absolute points) 0.7 0.9 0.79
OMT = optimal medical therapy; SWT= segmental wall thickness at systolic vs diastole by CMR.

aPrimary endpoint.

Also similar in the two groups were changes in global LV function by CMR, LVEF, and LV end-diastolic volume.

"If we are not treating CTO to improve ventricular function, do we need additional evidence to prove that treating ischemic myocardium in symptomatic patients relieves angina and improves quality of life?" Jaber asks.

"The answer is probably yes," he writes, especially considering the sham-controlled ORBITA trial, which questioned whether PCI is better than optimal medication in patients with single-vessel stable coronary disease.

Jaber points to the single-center but randomized Sham-Controlled Intervention to Improve Quality of Life in CTOs (SHINE-CTO) trial currently underway, with a projected enrollment of 142 patients, to shed more light on the question.

The investigator-initiated study was supported by a grant from Cordis. Mashayekhi and his coauthors had no disclosures. Jaber discloses being on an advisory board for Medtronic and receiving proctoring fees from Abbott Vascular.

JACC Cardiovasc Intervent. Published online September 12, 2018. Abstract, Editorial

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