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Cost-Effectiveness in Patients Undergoing Revascularization of Chronic Total Occluded Coronary Arteries—A Cohort Study

Key messages:

  • Currently, patients with chronic total occluded coronary arteries (CTO) and symptoms despite medical therapy are recommended to undergo revascularisation, however the economic considerations need to be taken into account when selecting a treatment strategy
  • This study investigated the difference in cost for the index procedure and subsequent admissions due to heart disease up to 3 years after percutaneous coronary intervention (PCI) procedures
  • This is the first study to investigate the long-term cost-efficiency of PCI in patients with CTO suggesting that preprocedural planning and abstaining from or referral of a complex CTO case is important for both reducing the overall healthcare expenses and improving the success rate for complex cases

Study Design:

This observational study investigated patients enrolled in the EUROCTO database from 2009 to 2019. The exposure of interest was successful revascularisation of all CTO lesions compared with having one or more remaining CTOs after PCI attempt(s) (unsuccessful). Non-CTO lesions were treated according to guidelines, while bystander CTO-lesions were left untreated. Major adverse cardio- and cerebrovascular events (MACCE) and admissions for cardiac symptoms were collected in the Western Denmark Heart Registry. Cost-effectiveness was assessed at 3 years post-treatment as the net benefit (NB) at the patient level. The cost was defined as the cumulative cost of the index procedure and admissions due to heart disease and the effectiveness was defined as the difference in MACCE, death and symptomatic admissions.

Primary endpoints:

  • Cumulative cost (NB) at patient-level 3 years after index CTO treatment between the successful and unsuccessful revascularisation

Secondary endpoints:

  • The difference in procedural cost and the cost per patient-year of follow-up

Inclusion criteria:

  • Patients who were registered in the EUROCTO database
  • History of CTO PCI at Aarhus University Hospital (2009–2019)
  • Citizens of the Central Region of Denmark at the time of event audit
  • Patients who had completed 3 years follow-up


  • In total, 441 patients with follow-up of more than 3 years were treated with PCI for at least one CTO lesion (342 in the successful group, 99 in the unsuccessful group)
  • The overall technical success rate was 85.4%
  • During the follow-up years, 155 MACCE, and 184 admissions due to suspected acute coronary syndrome occurred (24.3% in the successful arm and 24.2% in the unsuccessful arm had at least one event)
  • The mean total cost was €11.719 (11.034; 12.406) and €13.565 (11.899; 15,231; p = 0.02) in the successful and unsuccessful groups, respectively.
  • After successful revascularisation for MACCE, the net-benefit was €1.846 (64; 3,627)
  • The adjusted analysis revealed an NB of €1,481 (–118; 3,079)
  • Bootstrap estimates of cost-effectiveness planes were in favour of successful revascularisation   


Patients fully revascularised for all CTO lesions both had a more cost-efficient treatment, and a lower event rate – suggesting that for these patients the treatment is neither harmful nor more expensive.


  • Retrospective analysis of prospectively collected data may lead to selection bias
  • Ischemic testing data for the first part of the study period were not available
  • Data were collected in a single centre
  • Only events requiring hospital admissions were evaluated, hence the cost may have been underestimated  
  • No control group being treated with optimal medical therapy alone was included