Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention in Isolated Chronic Total Occlusion of the Left Anterior Descending Artery: The RITUAL Study

Background The optimal revascularization strategy for isolated left anterior descending artery chronic total occlusion (CTO) remains uncertain, with limited comparative data between CTO percutaneous coronary intervention (CTO‐PCI) and coronary artery bypass grafting (CABG). Methods The RITUAL (Revascularization of Isolated Chronic Total Occlusion of the Left Anterior Descending Artery) study was a retrospective, multicenter analysis conducted at 4 centers including patients who underwent revascularization for isolated left anterior descending artery CTO between January 2017 and January 2023. Lesion complexity was assessed using the Japanese Chronic Total Occlusion score. The primary end point was technical and procedural success. Secondary end points included 3‐year major adverse cardiac and cerebrovascular events and a periprocedural composite safety outcome. Multivariable Cox regression and restricted cubic spline analyses were performed. Results Among 2382 patients treated with CTO‐PCI and 5850 surgical patients screened, 297 eligible patients (184 CTO‐PCI, 113 CABG) were analyzed. Baseline characteristics were comparable. Adjusted procedural success favored CTO‐PCI (88.6% versus 83.2%; adjusted hazard ratio [HR], 1.33 [95% CI, 1.01–1.75]; P =0.043), while technical success was similar. CABG was associated with higher rates of acute kidney injury and blood transfusion. At 3 years, all‐cause death and major adverse cardiac and cerebrovascular events were comparable. However, adjusted periprocedural composite safety outcomes were lower with CTO‐PCI (20.7% versus 35.4%; adjusted HR, 0.63 [95% CI, 0.40–0.99]; P =0.047). Increasing Japanese Chronic Total Occlusion score was linearly associated with higher major adverse cardiac and cerebrovascular event risk ( P =0.007), and among patients with a Japanese Chronic Total Occlusion score <3, periprocedural composite safety outcomes favored CTO‐PCI. Conclusions In isolated left anterior descending artery CTO, no significant differences in 3‐year clinical outcomes were observed between CABG and CTO‐PCI, although CABG was associated with higher in‐hospital complications and CTO‐PCI with more favorable periprocedural composite safety outcomes, particularly in less complex lesions. Registration URL: https://clinicaltrials.gov ; Unique identifier: NCT07373678.