Background: Chronic total occlusion (CTO) is a common finding in patients with obstructive coronary artery disease. Therapeutic regimes include medical treatment or revascularization via percutaneous coronary intervention (PCI). Indication for revascularization may be regional ischemia with preserved vitality or refractory symptoms such as angina pectoris. The current meta-analysis aimed to assess the effects of PCI in comparison to optimal medical treatment (OMT) in treatment of CTO on clinically relevant endpoints.

Methods: A literature search was performed using Medline, Web of Sciences, and Cochrane Library to identify potential studies published since 01.01.2010. The last search was performed on 26.10.2022. Records and full-text articles were independently screened by two authors (SMM, KS). All randomized and non-randomized controlled trials (RCT and non-RCT) assessing the effect of PCI versus OMT in patients with CTO were eligible. In non-randomized trials, matched data were preferred over crude data. The primary end point was major adverse cardiovascular events (MACE), a composite of all-cause mortality, myocardial infarction, stroke, and target vessel revascularization. The individual components were separately analyzed as secondary efficacy endpoints.

Results: Sixteen cohorts reported in 45 full-text publications were identified through the search and fifteen cohorts were eligible for quantitative analysis. Overall, 9771 patients with CTO were included in statistical analyses. Of these, 4679 patients underwent CTO PCI and 5092 patients were treated with optimal medical treatment. PCI led to a significant risk reduction in MACE compared to OMT (OR 0.56; 95% CI: 0.38-0.83, p=0.01, I²: 62%), this effect was sustained in subgroup analyses of RCTs and non-RCTs (figure 1). In the overall analysis, PCI was associated with significantly reduced all-cause mortality compared to OMT (OR 0.57; 95% CI: 0.42-0.77, p<0.001, I²: 64%). This was mainly driven by the subgroup of non-RCTs, but not by the RCTs (OR 1.10; 95% CI: 0.49-2.47, p=0.82, I²: 37%). Patients undergoing PCI had a 47% lower likelihood to suffer a stroke in comparison with OMT (OR 0.53; 95% CI: 0.28-0.97, p=0.04, I²: 0%). The risk of myocardial infarction (OR 0.84; 95% CI: 0.65-1.09, p=0.2, I²: 33%) or the need for target vessel revascularization did not significantly differ between the groups (OR 0.81; 95% CI: 0.50-1.30, p=0.38, I²: 78%).

PCI of CTO was associated with a significant decrease of major adverse cardiovascular events compared to optimal medical treatment. Patients undergoing interventional revascularization had a lower likelihood of stroke during the observational period, but no difference was observed in all-cause mortality according to treatment strategy.