Opening Chronically Blocked Heart Arteries in Patients Over 80 Proves Feasible

Opening chronically blocked coronary arteries in patients aged 80 and older carries in-hospital and one-year outcomes broadly comparable to those seen in younger patients, according to a single-center analysis published in Cardiology and Therapy. Researchers at the Heart Center, Segeberger Kliniken, in Bad Segeberg, Germany, reviewed 735 patients who underwent successful percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) between January 2017 and December 2022. Of these, 123 were octogenarians, defined as aged 80 or older but younger than 90, while 612 patients formed a younger control group under 80. The study, drawn from the Prospective Segeberg Registry for Coronary Chronic Total Occlusions, is described by its authors as the largest single-center investigation of in-hospital and one-year outcomes after CTO-PCI in this age group.

A coronary chronic total occlusion is defined as a complete blockage of a coronary artery lasting at least three months, with no blood flow through the vessel as graded by the TIMI scale. CTO is considered the final stage of coronary artery disease progression and is present in an estimated 15 to 25 percent of patients. Its prevalence rises with age, and roughly 30 percent of older patients with symptoms of myocardial ischemia are reported to have a CTO on their coronary angiogram. Yet only 8 to 15 percent of CTO cases are referred for PCI, with the remainder managed primarily with optimal medical therapy. Older patients are usually excluded from randomized trials, so the available evidence on CTO recanalization rests almost entirely on cohorts of younger patients with fewer comorbidities, leaving guideline recommendations for the very old poorly supported.

The retrospective analysis divided consecutive patients into the two age groups and compared baseline characteristics, procedural results, in-hospital events and one-year follow-up. The mean age of the octogenarian group was 82.9 years, against 65.9 years in the younger cohort, and 566 of the 735 patients, or 77 percent, were men. The older patients carried a heavier comorbidity burden: arterial hypertension was present in 96.7 percent versus 91.2 percent of younger patients, atrial fibrillation in 28.5 percent versus 12.1 percent, and chronic kidney disease in 34.1 percent versus 16.5 percent. Conversely, the octogenarians had significantly lower rates of dyslipidemia and of a previous myocardial infarction. Severely calcified CTO segments were more frequent in the older group, at 62.4 percent versus 55.1 percent, while other angiographic and procedural characteristics were comparable.

Procedural success itself differed markedly between the age groups. When all attempted CTO procedures were considered, including the 83 failed attempts excluded from the main analysis, recanalization failed in 18.5 percent of octogenarians compared with 8.2 percent of younger patients, a statistically significant difference. The overall procedural success rate in the full cohort was 90.1 percent, but it fell to 81.5 percent in octogenarians against 91.9 percent in younger patients. The authors attribute this gap to more advanced coronary artery disease in older patients, characterized by extensive calcification and vessel tortuosity, and speculate that delayed presentation with atypical symptoms and operators’ reluctance to persist with complex lesions in the very old may also contribute.

Despite the lower success rate, the safety picture inside the hospital was largely reassuring. In-hospital major adverse cardiac and cerebrovascular events, a composite of cardiac death, periprocedural myocardial infarction, stroke or transient ischemic attack, and emergency bypass surgery, occurred in 8.1 percent of octogenarians and 8.7 percent of younger patients, a non-significant difference. Periprocedural myocardial infarction affected 6.5 percent versus 7.5 percent, and no octogenarian suffered an in-hospital stroke or required emergency bypass surgery. In-hospital mortality was numerically higher in the older group, at 2.4 percent versus 0.8 percent, but this difference did not reach statistical significance. The same pattern held when all 818 attempted procedures, including failures, were analyzed: mortality was 2.6 percent versus 0.8 percent, and overall in-hospital events remained comparable.

One complication did stand out. Contrast-induced nephropathy, defined as a rise in serum creatinine of at least 0.5 milligrams per deciliter or 25 percent within 48 to 72 hours of contrast exposure, developed in 11.4 percent of octogenarians versus 4.9 percent of younger patients, a significant difference. The authors link this to the higher prevalence of pre-existing chronic kidney disease in the older group. A sub-analysis found no significant difference in hospital stay length between patients with and without this kidney injury, but dialysis was required significantly more often by those who developed it. The center’s protocol already includes intravenous fluid administration before and during the procedure and minimization of contrast volume through a reference angiogram with dual injection.

At one year, the primary endpoint of target lesion failure, a composite of cardiac death, myocardial infarction, or repeat revascularization of the treated segment, did not differ significantly between groups. It occurred in 16.2 percent of octogenarians and 12.3 percent of younger patients, with an adjusted hazard ratio of 1.52 and a confidence interval spanning 0.81 to 2.84. However, cumulative cardiac mortality at one year was significantly higher in the octogenarian group, at 7.6 percent versus 2.7 percent, with a hazard ratio of 2.82. The investigators identified 13 cardiac deaths among the older patients: four occurred during the index hospitalization, three were attributed to decompensated heart failure, four were classified as sudden cardiac deaths, and two occurred in other circumstances, including one following orthopedic surgery. Rates of myocardial infarction and target lesion revascularization at one year were not significantly different between the groups.

Multivariate regression analysis pointed away from age itself as the driver of target lesion failure. Diabetes mellitus, chronic obstructive pulmonary disease, atrial fibrillation, and a longer total stent length emerged as independent predictors of the one-year endpoint, with adjusted hazard ratios of 1.46, 1.97, 2.13, and 2.01 respectively, while octogenarian status per se was not significant. The authors note that diabetes has previously been associated with increased target lesion failure after non-CTO PCI, and that COPD and atrial fibrillation predict higher long-term mortality after such procedures. They also report that cardiac death and myocardial infarction rates in their octogenarian cohort resembled those published for octogenarians undergoing non-CTO PCI, suggesting the occluded lesion itself does not directly drive these events.

The study’s limitations are substantial and acknowledged by the authors. The design was single-center, retrospective, and non-randomized, exposing the results to operator bias and unmeasured confounding, and the findings cannot be generalized without validation in larger or randomized cohorts. No frailty assessment was performed, although frailty may be more informative than chronological age in this population, and no quality-of-life or symptom relief data were collected, endpoints the authors consider particularly relevant for octogenarians. The registry was retrospectively registered on ClinicalTrials.gov in May 2025. Current guidelines recommend treating coronary CTO in symptomatic patients on optimal drug therapy with evidence of ischemia and viability, and the authors emphasize that the potential benefits and risks of intervention must be weighed carefully in frail older patients with reduced life expectancy.

Within those constraints, the analysis suggests that age alone need not exclude patients over 80 from attempted recanalization of chronic total occlusions. In-hospital event rates, periprocedural complications other than contrast-induced kidney injury, and one-year target lesion failure were statistically indistinguishable from those of younger patients, even though the older group had more calcified lesions, more comorbidities, and a lower chance of crossing the blockage. The authors conclude that these findings raise questions about the safety and feasibility of the procedure in octogenarians and underscore the importance of careful patient selection, particularly among frail older candidates, while noting that octogenarians remain inherently at higher long-term mortality risk regardless of the intervention.

Subject of Research: Outcomes of chronic total occlusion percutaneous coronary intervention in octogenarians

Article Title: In-Hospital and One-Year Outcomes After Percutaneous Coronary Intervention for Chronic Coronary Occlusion in Octogenarians

Article References: Amoey, D., Elbasha, K., Samy, M., Landt, M., Kurniadi, A., Schiopu, O., Allali, A., Saad, M., Hofmann, F. J., Frank, D., Toelg, R., Richardt, G., Fichtlscherer, S., Nef, H., & Mankerious, N. (2026). In-Hospital and One-Year Outcomes After Percutaneous Coronary Intervention for Chronic Coronary Occlusion in Octogenarians. Cardiology and Therapy. https://doi.org/10.1007/s40119-026-00485-1

Image Credits: AI Generated

DOI: 10.1007/s40119-026-00485-1

Keywords: chronic total occlusion, percutaneous coronary intervention, octogenarians, target lesion failure, contrast-induced nephropathy, cardiac mortality, coronary artery disease, single-center registry, comorbidities, procedural success, In-Hospital, One-Year