Re: “Chronic Total Occlusion: Current Methods of Revascularisation” by Patrick T. Siegrist and Satoru Sumitsuji (Cardiovascular Medicine. 2014;17(12):347–356)

I think a few comments regarding this article are warranted. The authors state that deobstruction of chronically occluded arteries results in improved clinical outcomes, including hard end-points. They cite three main references to support this statement:

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Olivari et al. (J Am Coll Cardiol. 2003;41: 1672–8). Although prospective, this is an observational study where outcomes of non-randomised patients were compared according to whether they had received percutaneous coronary intervention (PCI) or not for a chronic obstruction. The decision to perform a PCI was not randomised.

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Suero et al. (J Am Coll Cardiol. 2001;38: 409–14). This study simply accounts for the results from the Canadian Registry and does not give any hint as to the change in outcome resulting from performing a PCI.

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Hoye et al. (Eur Heart J. 2005;26:2630–6). This is a retrospective study performed on patients recruited at the Thoraxcenter in Rotterdam. Outcome is compared between patients with successful PCI vs unsuccessful. The possibility of bias is therefore very important, all the more so as the major effect on outcome is on the need for renewed revascularisation …

I am surprised, therefore, that the authors did not consider citing the OAT study (N Engl J Med 2006;355:2395–407), as this study is not only more recent than the ones cited by the authors but is also the only one with randomisation: patients with an occluded coronary artery were randomised either to undergo or not to undergo PCI. The results were very clear in that there was no benefit with PCI. One should note that the study was performed in patients at high risk, notably by being 3–28 days postmyocardial infarction. Admittedly, these represent patients for whom PCI is usually not discussed, making the results all the more interesting.

I think that before considering the merits of new devices and techniques, one should remember that in patients with total chronic occlusion, the discussion as to when and in whom PCI should be performed is still open.