Early Versus Late Chronic Total Occlusion Percutaneous Coronary Intervention: CRM, May 2025 Finds

These findings are published in May 2025 in Cardiovascular Revascularization Medicine

The Burden of ACS

ACS, which includes both ST-Elevation Myocardial Infarction (STEMI) and Non-ST Elevation Myocardial Infarction (NSTEMI), often involves multi-vessel disease. While European guidelines recommend complete revascularization within 45 days, it has remained unclear if this timeline should apply to a Chronic Total Occlusion (CTO)—a complete blockage of a coronary artery for over three months. These lesions are technically demanding and carry higher procedural risks than standard blockages, necessitating localized data to determine if immediate intervention is superior to a staged, late approach.

Study Overview

The retrospective, international multicenter analysis involved seven specialized centers in Spain and Italy, evaluating 215 patients who underwent successful revascularization of a culprit lesion followed by a planned intervention for a non-culprit chronic total occlusion. The study population was divided into an "early" group, defined as treatment within 45 days, and a "late" group, receiving treatment between 45 days and 6 months. Researchers focused on a composite primary endpoint of all-cause death, myocardial infarction (MI), any subsequent revascularization, and cardiac-related rehospitalization.

The key findings from the study include:

• Among the 215 subjects, 119 patients underwent early CTO-PCI while 96 received late intervention

• At the three-year mark, MACE occurred in 28.8% of the early group compared to 23.2% in the late group, representing a statistically insignificant difference

• Late intervention patients often presented with more complex procedural features, such as higher J-Chronic Total Occlusion (J-CTO) scores and slightly lower Left Ventricular Ejection Fraction (LVEF) values

• Evidence of positive myocardial viability was significantly more prevalent in the late group (72.9%) than in the early group (33.6%), suggesting a more selective clinical approach for delayed cases.

Clinical Relevance and Strategic Planning

For practicing cardiologists, this research indicates that the 45-day window suggested by European guidelines may not be mandatory for CTO. The lack of additional benefit from early intervention supports a more selective, planned approach for complex blockages. Deferring the procedure allows the inflamed post-infarction myocardium to stabilize, potentially reducing the risks of arrhythmias or further damage during difficult recanalization. Ultimately, meticulous pre-procedural planning and the assessment of myocardial viability should take precedence over rapid revascularization to ensure optimal long-term patient outcomes.

Reference

Paolucci L, Diego-Nieto A, Jurado-Román A, et al. Timing of chronic total occlusion percutaneous coronary intervention in acute coronary syndromes: Early versus late complete revascularization and clinical outcomes. Cardiovascular Revascularization Medicine. 2026; 83: 1–7