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Background <p>The prognostic benefit of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) in stable coronary artery disease (CAD) remains uncertain.</p> Objectives <p>To evaluate long-term survival following CTO PCI compared with medical therapy (MT) using target trial emulation and a nationwide real-world registry.</p> Methods <p>We included 7813 patients with stable CAD and a documented CTO from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR) between 2015 and 2024. CTO PCI was modeled as a time-dependent exposure. The primary outcome was all-cause mortality. We used inverse probability of treatment weighting (IPTW), time-dependent Cox regression, and instrumental variable (IV) analysis to adjust for confounding.</p> Results <p>Over a median follow-up of 5.08&#xa0;years, 1253 deaths occurred. While unadjusted survival favored CTO PCI (HR 0.74; 95% CI, 0.64–0.86; <i>p</i> &lt; 0.001), IPTW and IV adjustment showed no significant reduction in mortality compared with MT (IPTW HR 0.94; 95% CI, 0.80–1.10; <i>p</i> = 0.41; IV HR 1.00; 95% CI, 0.71–1.40; <i>p</i> = 0.999). Successful CTO PCI was associated with improved survival (HR 0.74; 95% CI, 0.62–0.87), whereas unsuccessful procedures were not (HR 1.08; 95% CI, 0.79–1.47). Subgroup analyses showed no consistent benefit, although a modest survival advantage was observed in non-diabetic patients.</p> Conclusions <p>In this large nationwide study using target trial emulation, CTO PCI was not associated with improved overall survival compared with MT. Only successful procedures conferred a benefit, highlighting the importance of procedural success and patient selection in CTO revascularization strategies.</p> Graphical Abstract <p></p>

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CTO PCI vs. medical therapy in stable CAD: real-world outcomes from a target trial emulation of SCAAR registry data

  • 期刊论文

  • 出版模式：

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  • 发表日期：

    2026年1月19日

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  • Joakim Sundström,
  • Antros Louca,
  • Petur Petursson,
  • Mohammed Mohammed,
  • Oskar Angerås,
  • Anna Myredal,
  • Sebastian Völz,
  • Christian Dworeck,
  • Jacob Odenstedt,
  • Göran Olivecrona,
  • Ulf Jensen,
  • Moman A. Mohammad,
  • Christos Pagonis,
  • David Erlinge,
  • Araz Rawshani,
  • Dan Ioanes,
  • Truls Råmunddal

摘要

Background

The prognostic benefit of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) in stable coronary artery disease (CAD) remains uncertain.

Objectives

To evaluate long-term survival following CTO PCI compared with medical therapy (MT) using target trial emulation and a nationwide real-world registry.

Methods

We included 7813 patients with stable CAD and a documented CTO from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR) between 2015 and 2024. CTO PCI was modeled as a time-dependent exposure. The primary outcome was all-cause mortality. We used inverse probability of treatment weighting (IPTW), time-dependent Cox regression, and instrumental variable (IV) analysis to adjust for confounding.

Results

Over a median follow-up of 5.08 years, 1253 deaths occurred. While unadjusted survival favored CTO PCI (HR 0.74; 95% CI, 0.64–0.86; p < 0.001), IPTW and IV adjustment showed no significant reduction in mortality compared with MT (IPTW HR 0.94; 95% CI, 0.80–1.10; p = 0.41; IV HR 1.00; 95% CI, 0.71–1.40; p = 0.999). Successful CTO PCI was associated with improved survival (HR 0.74; 95% CI, 0.62–0.87), whereas unsuccessful procedures were not (HR 1.08; 95% CI, 0.79–1.47). Subgroup analyses showed no consistent benefit, although a modest survival advantage was observed in non-diabetic patients.

Conclusions

In this large nationwide study using target trial emulation, CTO PCI was not associated with improved overall survival compared with MT. Only successful procedures conferred a benefit, highlighting the importance of procedural success and patient selection in CTO revascularization strategies.

Graphical Abstract