Response to Weintraub and Garratt
The article by Weintraub and Garratt includes the following key points: (1) the use of coronary artery bypass graft (CABG) to treat chronic total occlusions (CTOs) is limited; (2) surgeons ignore CTOs, simply bypassing them if viability and coronary size >1mm are confirmed; (3) CABG-CTOs can be justified in the setting of multivessel disease; and (4) the concluding remark is “While carrying out studies concerning CABG for CTOs will be difficult, a research agenda in this space is clearly needed.”
The article omits the following facts: (1) CTOs represent a technical challenge only for interventional cardiologists; (2) surgeons do not worry excessively about CTOs, simply bypassing them if viability and coronary size >1 mm are confirmed; (3) since the advent of CABG, CTO has never been an exclusion criterion, with millions of CTOs bypassed; (4) surgeons only treat patients referred by cardiologists; and (5) the Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) trial confirms the disproportionate inferiority of percutaneous coronary intervention (PCI) versus CABG for large cohorts of CTOs. In addition, the article fails to note that the presumed efficacy of CTO-PCI is only based on comfortable comparisons between successful versus failed procedures, with no controls. The fact that failed CTO-PCI procedures are causing severe iatrogenic injury to thousands of patients, resulting in many deaths, is not represented. This is of concern. Choosing to not report these safety issues may contribute to the disproportionate emphasis on the efficacy of CTO-PCI, which appears to be defined, on no clinical grounds, as on-table recanalization only.
In this scenario, the call by Weintraub and Garratt for research on the efficacy of CABG-CTO appears misplaced. Clearly, the research focus should be on the safety of CTO-PCI as a potential alternative to medical therapy alone.
- © 2016 American Heart Association, Inc.