Dr Mark Gunning (University Hospital of North Midlands, Stoke-on-Trent, UK) discusses the cost-effectiveness and efficacy of percutaneous coronary intervention for chronic total occlusion (CTO PCI).

Questions:
 
1. Which patients should be considered for CTO PCI and which should be referred to surgery? 
2. Why is there a debate as to whether CTO PCIs are cost-effective? 
3. What is your opinion on this matter? 
4. Does the type of CTO technique influence the cost-effectiveness? 
5. What is needed to silence the naysayers? 
 

Filmed in London at BCIS ACI 2020.

Interviewer: Mirjam Boros 
Videographer: Natacha Wienand / Dominic Woodruff

Transcript Below : 

Question 1 : Which patients should be considered for CTO PCI and which should be referred to surgery?

Well the advances that have taken place in CTO PCI mean that there are cases which can be treated interventionally now that may have not been considered for percutaneous treatment in time gone past. So the answer to that question here in 2020 is very different to where it was 10 or 15 years ago. The fact of the matter is that we look not not only as at the individual lesion but rather the multi-vessel disease. So if the patients have a high syntax score they should be referred on for bypass surgery. But the fact that there are blockages in various vessels does not preclude the use of percutaneous approach. Particularly with the skills of some of those specialist operators. 

Question 2 : Why is there a debate as to whether CTO PCIs are cost-effective?

Well one of the difficulties with very complex disease is that it is time consuming and involves specialist equipment. So for example there are operators who will dedicate perhaps two hours to a case to open up a single vessel and use a variety of different wires or burrowing devices if you like in order to get through what is effectively a collapsed mining tunnel to get through to the other side. And the expenditure for the sake of that single vessel is very much more than it would be for the next case that may appear on the table. And it is for this reason that people are debating it, the detractors would be other operators within the catheter lab or healthcare managers who are looking at the budget for the department as a whole. 

Question 3 : What is your opinion on this matter?

My opinion is that the patients who have intractable symptoms despite medical treatment do benefit from a CTO procedure when it is successful. And I say that as someone who refers through to a specialist operator rather than a personal enthusiast myself. So therefore I feel that those patients are worthy of the treatment and when we employ the skills of those dedicated operators it is worthwhile. The real objective here is to make people feel better and that objective is achieved when the vessel is opened. 

Question 4 : Does the type of CTO technique influence the cost-effectiveness?

Yes it does because if an amateur operator as it were, were to take on a fairly complex occlusion, the likelihood of success would be low, the possibility of an adverse event would be greater and therefore when we have somebody who is using all of the very best techniques and equipment, they maximise their chance of success. We see in some of the series that are published where the success with this difficult field of angioplasty is high as 90%, which is amazing and compares very favourably indeed to the pervious sort of figures which were around 50-50. So I do think that the advances both in terms of knowledge and in terms of the equipment have made a big difference in this field. 

Question 5 : What is needed to silence the naysayers?

Well I think what's important is to maintain the principle that the objective here, it's Hippocratic in its own way, is to make people feel better and to relive distress. And if we really maintain that argument and indicate that this is for the purposes of symptom relief rather than strong evidence to indicate that we're altering prognosis then the argument in favour of CTO PCI is robust.