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Lawton et al 2021 ACC/AHA/SCAI Coronary Revascularization Guideline January 18, 2022 Circulation. 2022;145:e18–e114. DOI: 10.1161/CIR.0000000000001038 e56 CLINICAL STATEMENTS AND GUIDELINES even after adjustment for baseline variables and propensity matching.10 Another observational study, examining patients with prior CABG undergoing PCI, reported higher rates of in-hospital death, noreflow, periprocedural MI, and cardiogenic shock in patients who underwent SVG PCI than in patients who underwent PCI of the native vessel. At 3 years, SVG PCI was associated with higher rates of post discharge death, MI, and repeat revascularization than those seen with native coronary PCI.5 3. In patients with chronic occlusion of an SVG, PCI of the SVG has been associated with low success rates and excessive risk of needing repeat intervention.7,8 However, experienced operators have used occluded SVGs as conduits for retrograde recanalization of CTOs in native coronary arteries.13 10.7 Treatment of CTO Recommendation for Treatment of CTO Referenced studies that support the recommendation are summarized in Online Data Supplement 29. COR LOE Recommendation 2b B-R 1. In patients with suitable anatomy who have refractory angina on medical therapy, after treatment of non-CTO lesions, the benefit of PCI of a CTO to improve symptoms is uncertain.1-4 Synopsis A CTO is found in approximately one-quarter of patients undergoing coronary angiography.5,6 Considerable progress in the technical aspects of interventional revascularization has yielded success rates in excess of 80% in the hands of skilled operators.7 However, the 30-day mortality rate after CTO PCI is 1.3%, and perforations occur in 4.8% of cases.8 Enthusiasm for treating these lesions was fueled by retrospective data suggesting improved clinical outcomes for those patients who underwent successful recanalization compared with those who had failed.9 However, RCTs have not demonstrated improved function4,10 and have been equivocal with regard to symptoms.1,2 For this reason, shared decision-making should inform the treatment of patients with refractory angina despite GDMT with remaining CTO coronary lesion, with careful discussions of the limitations of treating these lesions, as well as the potential benefits. Recommendation-Specific Supportive Text 1. Despite considerable retrospective and registry data suggesting a clinical benefit of PCI of a CTO, a clear demonstration of benefit from prospective randomized trials has not been forthcoming.11,12 The EXPLORE (Evaluating Xience and left ventricular function in PCI on occlusions after STEMI) and the REVASC (Randomized Trial to Assess Regional Left Ventricular Function After Stent Implantation in Chronic Total Occlusion) trials did not demonstrate any improvement in ventricular function with CTO PCI versus optimal medical therapy.4,10 Although the EURO CTO (Randomized Multicentre Trial to Compare Revascularization With Optimal Medical Therapy for the Treatment of Chronic Total Occlusions) trial demonstrated a greater reduction in angina frequency and improved quality of life with PCI of a CTO than with optimal medical therapy,2 a much larger trial, the DECISION-CTO (Drug-Eluting Stent Implantation Versus Optimal Medical Treatment in Patients With Chronic Total Occlusion) trial, did not demonstrate any difference in symptoms or clinical outcomes with CTO PCI.1 Future trials with more definitive endpoints may change the current landscape.3,13,14 10.8 Treatment of Patients With Stent Restenosis Recommendations for Treatment of Patients With Stent Restenosis Referenced studies that support the recommendations are summarized in Online Data Supplement 30. COR LOE Recommendations 1 A 1. In patients who develop clinical in-stent restenosis (ISR) for whom repeat PCI is planned, a DES should be used to improve outcomes if anatomic factors are appropriate and the patient is able to comply with DAPT.1-4 2a C-EO 2. In patients with symptomatic recurrent diffuse ISR with an indication for revascularization, CABG can be useful over repeat PCI to reduce recurrent events. 2b B-NR 3. In patients who develop recurrent ISR, brachytherapy may be considered to improve symptoms.5 Synopsis The increasing use of newer-generation DES has led to a significant reduction in the risk of ISR and subsequent target-lesion revascularization compared with BMS and first-generation DES.6-8 Nevertheless, ISR is still reported in 5% to 10% of patients undergoing PCI.9,10 The primary mechanism of ISR after stent implantation is neointimal hyperplasia, with angiographic and histopathological studies demonstrating considerable differences in tissue characteristics based on the type of stent.11-14 The risk of restenosis is also linked to clinical presentation, patient profile, lesion location, and procedural characteristics.15,16 Numerous approaches to the treatment of restenosis have been explored and include balloon angioplasty, DES, drug-coated balloons, scoring or cutting balloons, vascular brachytherapy, atheroablative therapies, and CABG. Compared with other therapies, DES appears to provide the most benefit. However, the type of ISR (ie, focal versus diffuse) may also affect the decision to treat with one modality over another and, therefore, treatment Downloaded from http://ahajournals.org by on October 7, 2026