The Gulf Chronic Total Occlusion Registry

Abstract

BACKGROUND: Chronic total occlusion (CTO) is associated with increased ischemic burden, heart failure, and mortality. Comparative clinical outcomes associated with medical therapy, percutaneous coronary intervention (PCI), and coronary artery bypass grafting (CABG) remain uncertain. OBJECTIVES: To compare clinical outcomes associated with medical therapy, PCI, and CABG in patients with CTO. METHODS: We analyzed 741 patients with angiographically confirmed CTO enrolled across 7 tertiary centers in 4 Gulf countries between 2021 and 2023. Patients were managed with an initial strategy of medical therapy (n = 151), PCI (n = 441), or CABG (n = 149). The primary in-hospital endpoint was major adverse cardiovascular events. The long-term endpoint was major adverse cardiac and cerebrovascular events-free survival. RESULTS: Treatment allocation differed substantially by baseline clinical and angiographic risk. Medically managed patients had worse renal function, more severely reduced left ventricular ejection fraction, and more cardiogenic shock despite simpler CTO anatomy CABG patients had more extensive multivessel disease, whereas PCI patients had greater CTO lesion complexity. After adjustment, neither PCI nor CABG differed significantly from medical therapy for in-hospital major adverse cardiovascular events. At a median follow-up of 22 months, adjusted 36-month restricted mean survival time analyses showed no statistically significant difference in major adverse cardiac and cerebrovascular events-free survival between PCI, CABG, and medical therapy. Adjusted Canadian Cardiovascular Society class I at last follow-up was reached in 86.2% of medical therapy, 91.7% of PCI, and 98.0% of CABG patients; the adjusted difference vs medical therapy was significant for CABG (P < 0.001) but not for PCI P = 0.17). CONCLUSIONS: After adjustment, no treatment strategy demonstrated superiority for hard cardiovascular outcomes; revascularization, particularly CABG, was associated with a lower angina burden at follow-up.