PDF icon Download PDF
Int J Angiol
DOI: 10.1055/a-2655-2536
Review Article

A Review of Indications and Guidelines of Chronic Total Occlusion Revascularization

Spas Kotev
1   Department of Cardiology, University of Iowa Health Care, Iowa City, Iowa
,
Farhad Sami
1   Department of Cardiology, University of Iowa Health Care, Iowa City, Iowa
,
Boniface Malangu
1   Department of Cardiology, University of Iowa Health Care, Iowa City, Iowa
› Author Affiliations
Funding None.
› Further Information
   Permissions and Reprints
Preview

Abstract

Chronic total occlusion (CTO), affecting 18 to 30% of coronary artery disease patients undergoing angiography, is linked to refractory angina, reduced left ventricular function, and increased arrhythmia risk. This article synthesizes indications, evidence, and guidelines for CTO revascularization, focusing on percutaneous coronary intervention (PCI). CTO PCI achieves over 85% success rates in expert hands, with randomized controlled trials showing improved symptom relief and quality of life, though mortality or ventricular function benefits remain unproven. The 2021 ACC/AHA/SCAI and 2018 ESC/EACTS guidelines recommend CTO PCI for refractory angina, emphasizing operator expertise and shared decision-making. Controversies persist regarding prognostic benefits and patient selection. Ongoing trials aim to clarify these issues. This review equips clinicians with a framework to navigate CTO management, balancing evidence and patient-centered care.

Keywords

coronary artery - coronary intervention - chronic total occlusion - guidelines - indications - coronary angiography


Publication History

Article published online:
04 August 2025

© 2025. International College of Angiology. This article is published by Thieme.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Ybarra LF, Rinfret S, Brilakis ES. et al.; Chronic Total Occlusion Academic Research Consortium. Definitions and clinical trial design principles for coronary artery chronic total occlusion therapies: CTO-ARC consensus recommendations. Circulation 2021; 143 (05) 479-500
    CrossrefPubMedSearch in Google Scholar
  • 2 Jeroudi OM, Alomar ME, Michael TT. et al. Prevalence and management of coronary chronic total occlusions in a tertiary Veterans Affairs hospital. Catheter Cardiovasc Interv 2014; 84 (04) 637-643
    PubMedSearch in Google Scholar
  • 3 Fefer P, Knudtson ML, Cheema AN. et al. Current perspectives on coronary chronic total occlusions: The Canadian Multicenter Chronic Total Occlusions Registry. J Am Coll Cardiol 2012; 59 (11) 991-997
    CrossrefPubMedSearch in Google Scholar
  • 4 Tsai TT, Stanislawski MA, Shunk KA. et al. Contemporary incidence, management, and long-term outcomes of percutaneous coronary interventions for chronic coronary artery total occlusions: Insights from the VA CART Program. JACC Cardiovasc Interv 2017; 10 (09) 866-875
    CrossrefPubMedSearch in Google Scholar
  • 5 Tajti P, Brilakis ES. Chronic Total Occlusion Percutaneous Coronary Intervention: Evidence and Controversies. J Am Heart Assoc 2018; 12 ;7 (02) e006732
    CrossrefPubMedSearch in Google Scholar
  • 6 Galassi A, Grantham A, Kandzari D. et al. Percutaneous treatment of coronary chronic total occlusions part 1: Rationale and outcomes. Interv Cardiol 2014; 9 (03) 195-200
    CrossrefPubMedSearch in Google Scholar
  • 7 Attar A, Sayadi M, Hosseinpour A. et al. Prevalence and clinical parameters associated with chronic total occlusions in patients with chronic coronary syndromes: Insights from a Nationwide Registry. Health Sci Rep 2025; 8 (03) e70583
    CrossrefPubMedSearch in Google Scholar
  • 8 van Veelen A, Verstraelen TE, Somsen YBO. et al.; DO-IT Investigators*. Impact of a chronic total coronary occlusion on the incidence of appropriate implantable cardioverter-defibrillator shocks and mortality: A substudy of the Dutch Outcome in ICD Therapy (DO-IT)) Registry. J Am Heart Assoc 2024; 13 (08) e032033
    CrossrefPubMedSearch in Google Scholar
  • 9 Sainsbury PA, Fisher M, de Silva R. Alternative interventions for refractory angina. Heart 2017; 103 (23) 1911-1922
    CrossrefPubMedSearch in Google Scholar
  • 10 Megaly M, Saad M, Tajti P. et al. Meta-analysis of the impact of successful chronic total occlusion percutaneous coronary intervention on left ventricular systolic function and reverse remodeling. J Interv Cardiol 2018; 31 (05) 562-571
    CrossrefPubMedSearch in Google Scholar
  • 11 Xu J, Patel A, Meraj P. Impact of chronic total occlusions on outcomes of patients with acute myocardial infarction undergoing percutaneous coronary intervention: A propensity-score-matched analysis using the National Inpatient Sample database. Cardiovasc Revasc Med 2022; 44: 14-18
    CrossrefPubMedSearch in Google Scholar
  • 12 Kucukseymen S, Iannaccone M, Grantham JA. et al. Association of successful percutaneous revascularization of chronic total occlusions with quality of life: A systematic review and meta-analysis. JAMA Netw Open 2023; 6 (07) e2324522
    CrossrefPubMedSearch in Google Scholar
  • 13 Srivatsa SS, Edwards WD, Boos CM. et al. Histologic correlates of angiographic chronic total coronary artery occlusions: Influence of occlusion duration on neovascular channel patterns and intimal plaque composition. J Am Coll Cardiol 1997; 29 (05) 955-963
    CrossrefPubMedSearch in Google Scholar
  • 14 Werner GS. The role of coronary collaterals in chronic total occlusions. Curr Cardiol Rev 2014; 10 (01) 57-64
    CrossrefPubMedSearch in Google Scholar
  • 15 Qintar M, Grantham JA, Sapontis J. et al. Dyspnea among patients with chronic total occlusions undergoing percutaneous coronary intervention: Prevalence and predictors of improvement. Circ Cardiovasc Qual Outcomes 2017; 10 (12) e003665
    CrossrefPubMedSearch in Google Scholar
  • 16 Hoebers LP, Claessen BE, Dangas GD, Råmunddal T, Mehran R, Henriques JP. Contemporary overview and clinical perspectives of chronic total occlusions. Nat Rev Cardiol 2014; 11 (08) 458-469
    CrossrefPubMedSearch in Google Scholar
  • 17 Godino C, Bassanelli G, Economou FI. et al. Predictors of cardiac death in patients with coronary chronic total occlusion not revascularized by PCI. Int J Cardiol 2013; 168 (02) 1402-1409
    CrossrefPubMedSearch in Google Scholar
  • 18 Assaf A, Sakhi R, Diletti R. et al. Incidence of ventricular arrhythmias in patients with chronic total coronary occlusion: Results of the VACTOR study. Int J Cardiol Heart Vasc 2023; 50: 101323
    PubMedSearch in Google Scholar
  • 19 Yoon YH, Han S, Kwon O. et al. Ischemic burden assessment using single photon emission computed tomography in single vessel chronic total occlusion of coronary artery. Korean Circ J 2022; 52 (02) 150-161
    CrossrefPubMedSearch in Google Scholar
  • 20 Schumacher SP, Stuijfzand WJ, de Winter RW. et al. Ischemic burden reduction and long-term clinical outcomes after chronic total occlusion percutaneous coronary intervention. JACC Cardiovasc Interv 2021; 14 (13) 1407-1418
    CrossrefPubMedSearch in Google Scholar
  • 21 Tajstra M, Pyka Ł, Gorol J. et al. Impact of chronic total occlusion of the coronary artery on long-term prognosis in patients with ischemic systolic heart failure: Insights from the COMMIT-HF Registry. JACC Cardiovasc Interv 2016; 9 (17) 1790-1797
    CrossrefPubMedSearch in Google Scholar
  • 22 Saad M, Fuernau G, Desch S. et al. Prognostic impact of non-culprit chronic total occlusions in infarct-related cardiogenic shock. Euro Interv 2018; 14: e306-e313
    PubMedSearch in Google Scholar
  • 23 Werner GS, Martin-Yuste V, Hildick-Smith D. et al.; EUROCTO trial investigators. A randomized multicentre trial to compare revascularization with optimal medical therapy for the treatment of chronic total coronary occlusions. Eur Heart J 2018; 39 (26) 2484-2493
    CrossrefPubMedSearch in Google Scholar
  • 24 Lee SW, Lee PH, Ahn JM. et al. Randomized trial evaluating percutaneous coronary intervention for the treatment of chronic total occlusion. Circulation 2019; 139 (14) 1674-1683
    CrossrefPubMedSearch in Google Scholar
  • 25 Obedinskiy AA, Kretov EI, Boukhris M. et al. The IMPACTOR-CTO trial. JACC Cardiovasc Interv 2018; 11 (13) 1309-1311
    CrossrefPubMedSearch in Google Scholar
  • 26 Mashayekhi K, Nührenberg TG, Toma A. et al. A randomized trial to assess regional left ventricular function after stent implantation in chronic total occlusion: The REVASC trial. JACC Cardiovasc Interv 2018; 11 (19) 1982-1991
    CrossrefPubMedSearch in Google Scholar
  • 27 Henriques JPS, Hoebers LP, Råmunddal T. et al. EXPLORE Trial Investigators. Percutaneous intervention for concurrent chronic total occlusions in patients with STEMI: The EXPLORE trial. J Am Coll Cardiol 2016; 68 (15) 1622-1632
    CrossrefPubMedSearch in Google Scholar
  • 28 Morino Y, Abe M, Morimoto T. et al. J-CTO Registry Investigators. Predicting successful guidewire crossing through chronic total occlusion of native coronary lesions within 30.  minutes: the J-CTO (Multicenter CTO Registry in Japan) score as a difficulty grading and time assessment tool. JACC Cardiovasc Interv 2011; 4 (02) 213-221
    CrossrefPubMedSearch in Google Scholar
  • 29 Lawton JS, Tamis-Holland JE, Bangalore S. et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2022; 145 (03) e4-e17 . Erratum in: Circulation 2022;145(11):e771
    PubMedSearch in Google Scholar
  • 30 Neumann FJ, Sousa-Uva M, Ahlsson A. et al.; ESC Scientific Document Group. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J 2019; 40 (02) 87-165
    CrossrefPubMedSearch in Google Scholar