Chronic Coronary Occlusions

Chronic coronary occlusions are particularly difficult to treat with PTCA in light of the high rate of procedural failure and recurrence. Three randomized controlled trials have investigated the utility of stents in this setting. The Stenting in Chronic Coronary Occlusion (SICCO) trial (63) randomized 119 patients with angiographically successful PTCA to adjunctive stent or no further interventional procedure. The stent group had less restenosis at 6-mo angiography compared with the PTCA alone group (34 vs 72%, p = 0.001). Long-term follow-up (mean 33 ± 6 mo) demonstrated that the stent group suffered fewer cardiac events (cardiovascular death, lesion-related acute MI, TLR, or angiographic demonstration of recurrent reocclusion) (24 vs 59%,p = 0.002) (64). The Groupo Italiano per lo Studio sullo Stent nelle Occlusioni Coronariche (GISSOC) trial (65) has a similar design with 110 patients. Angiographic follow-up at 9 mo demonstrated larger mean diameters, less reocclusion, less recurrent ischemia, less TLR, and, notably, less restenosis (32 vs 68%,p < 0.001). The Total Occlusion Study of Canada (TOSCA) (66) trial randomized 410 patients to PTCA vs PTCA and stent after passing the guidewire (crossover rate 10%). Maintenance of TIMI 3 grade flow (the primary end point) was significantly higher in the stent group (89.1 vs 80.5%, p = 0.024). The stent group also had a lower restenosis rate (55 vs 70%,p < 0.01), and less TVR (8.4 vs 15.4%,p = 0.03).

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