Percutaneous coronary intervention for in-stent chronic total occlusion achieved similar technical success rates (OR 0.97) compared to de novo lesions, despite a higher long-term risk of MACE.
Meta-Analysis (n=725,906)
Yes
Does percutaneous coronary intervention for in-stent CTO have similar technical success and clinical outcomes compared to de novo CTO?
In-stent CTO PCI achieves similar technical success and short-term safety as de novo CTO PCI, but is associated with a higher long-term risk of MACE, MI, and target vessel revascularization.
Effect estimate: OR 0.97 (95% CI 0.87-1.08)
Absolute Event Rate: 89.9% vs 92.5%
p-value: p=0.67
Qiongya Mao,1 Lili Xie,1 Jun Wu2 1Nursing Department, Ningbo Municipal Hospital of Traditional Chinese Medicine, Affiliated to Zhejiang Chinese Medical University, Ningbo City, Zhejiang Province, 315010, Peopleâs Republic of China; 2Department of Andrology, Ningbo Traditional Chinese Medicine Hospital, Ningbo City, Zhejiang Province, 315010, Peopleâs Republic of ChinaCorrespondence: Jun Wu, Department of Andrology, Ningbo Traditional Chinese Medicine Hospital, No. 819 Liyuan North Road, Haishu District, Ningbo City, Zhejiang Province, 315010, Peopleâs Republic of China, Email vipfish@126.comBackground: Chronic coronary total occlusion (CTO) represents a formidable challenge in interventional cardiology, occurring either within previously implanted stents (in-stent CTO) or in non-stented native vessels (de novo CTO). We aimed to compare the outcomes of percutaneous coronary intervention (PCI) between patients with in-stent and de novo CTO through a systematic review and meta-analysis.Methods: PubMed, Embase, ScienceDirect, CENTRAL, and Google Scholar databases were searched for comparative studies published up to 20th September 20, 2025. A meta-analysis was conducted to calculate the odds ratios (OR) using a random effects model.Results: Nineteen studies that compared 73,945 patients with in-stent CTO and 651,961 patients with de novo CTO were included. There was no statistically significant difference in technical success between the two groups (OR, 0.97; 95% CI, 0.87, 1.08; I2=0%; p=0.67). Pooled analysis of early outcomes demonstrated no statistically significant difference in the risk of all-cause mortality, major adverse cardiovascular events (MACE), myocardial infarction (MI), stent thrombosis, or tamponade between the two groups. We also noted no statistically significant differences in long-term all-cause or cardiac mortality between the two groups. However, a meta-analysis of long-term data indicated that patients with in-stent CTO have a statistically significantly increased risk of MACE, MI, and target vessel revascularization (TVR) compared to those with de novo CTO.Conclusion: Our results indicate that in-stent CTO-PCI has success rates similar to those of de novo CTO-PCI. There was no difference in short-term adverse outcomes between the two groups; however, patients undergoing in-stent CTO PCI had an increased risk of MACE and MI, mainly driven by the significantly increased need for TVR.Keywords: coronary artery disease, mortality, percutaneous coronary intervention, chronic total occlusion
“What I always tell my fellows is to remember when we're looking at CTOs is that the C stands for chronic. One has to be sure that the patient is going to actually benefit from the intervention, either in terms of survival because there's a large ischemic hibernating area of myocardium or quality of life due to improvement in angina, and to be relatively sure that we're not just performing cosmetic surgery.”
Mao et al. (2026) conducted a meta-analysis in Chronic coronary total occlusion (CTO) (n=725,906). Percutaneous coronary intervention (PCI) for in-stent CTO vs. Percutaneous coronary intervention (PCI) for de novo CTO was evaluated on Technical success (residual stenosis <30% and TIMI flow grade ≥3) (OR 0.97, 95% CI 0.87-1.08, p=0.67). Percutaneous coronary intervention for in-stent chronic total occlusion achieved similar technical success rates (OR 0.97) compared to de novo lesions, despite a higher long-term risk of MACE.