Timing of chronic total occlusion percutaneous coronary intervention in acute coronary syndromes: Early versus late complete revascularization and clinical outcomes.

Background: European guidelines recommend early complete revascularization in patients with multivessel disease presenting with acute coronary syndrome (ACS). However, it remains unclear whether this strategy should also apply to patients with non-culprit chronic total occlusions (CTO).

Methods: We conducted a retrospective, multicenter analysis of patients with ACS who underwent successful percutaneous coronary intervention (PCI) of the culprit lesion and later underwent CTO-PCI of a non-culprit lesion as part of a complete revascularization strategy. Patients were divided into two groups: "early CTO-PCI" (≤45 days) and "late CTO-PCI" (> 45 days to ≤ 6 months). The primary endpoint was a composite of all-cause death, myocardial infarction, any revascularization, and cardiac re-hospitalization.

Results: Overall, 215 patients were included (119 early CTO-PCI, 96 late CTO-PCI). Patients in the late CTO-PCI group had more complex procedural features, reduced ventricular function, and a higher prevalence of demonstrable myocardial viability. The incidence of the primary outcome was comparable between the two groups at three years of follow-up (HR 0.94, 95 % CI 0.52-1.62). The same results were evident for its individual components, in sensitivity analysis at one year of follow-up, and after adjusting for major confounders.

Conclusions: Among ACS patients who underwent successful revascularization of non-culprit CTO lesions as part of complete revascularization, an early CTO-PCI strategy within 45 days does not confer additional clinical benefit compared to delayed intervention.