Chronic Total OcclusionRITUALNCT07373678
CABG Versus PCI in Patients With Isolated LAD Chronic Total Occlusion
An observational study of Chronic Total Occlusion, run by Mersin Medicalpark Hastanesi at 1 site in Turkey (Türkiye).
Trial summary
The aim of this study is to compare coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in the treatment of isolated chronic total occlusion (CTO) of the left anterior descending (LAD) artery in terms of short- and mid-term clinical outcomes, myocardial revascularization success, and… Read more about this study
- Who is it for?
- Ages 18 years and older
- Conditions the study is for
- Chronic Total Occlusion
- What is being tested?
- Coronary Artery Bypass Grafting and Percutaneous Coronary Intervention
- Type of treatment
- Surgery or procedure
- How many people
- 302 participants
- Where
- 1 siteTurkey (Türkiye)
- Study dates
- 10 Sep 2025to 15 Jan 2026
- Phase
- Observational
- Are there results?
- None posted in the registry
Key requirements
Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.
- Ages 18 years and older
- All sexes
- No healthy volunteers
- Adult, Older adult
Study population: The study population consists of adult patients aged 18 years or older with isolated chronic total occlusion (CTO) of the left anterior descending (LAD) coronary artery who underwent coronary revascularization with either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) as part of routine clinical care. Isolated LAD CTO was defined as a de novo or in-stent total occlusion confined to the LAD artery, without significant coronary artery disease (≥50% stenosis) in other major epicardial coronary arteries. Patients with prior coronary revascularization, multiple CTOs, severe left ventricular dysfunction, or incomplete follow-up data were excluded.
Who may be able to join
- Age 18 years or older at the time of the index procedure.
- Diagnosis of isolated chronic total occlusion (CTO) of the left anterior descending (LAD) coronary artery.
- Isolated LAD CTO defined as a de novo or in-stent total occlusion confined to the LAD artery, without significant coronary artery disease (defined as ≥50% stenosis) in other major epicardial coronary arteries, including the left circumflex (LCx), right coronary artery (RCA), or major side branches.
- No prior percutaneous coronary intervention (PCI) performed in non-LAD coronary arteries.
- Patients who underwent coronary revascularization with either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) for isolated LAD CTO.
Who cannot join
- History of malignancy or active malignant disease at the time of the index procedure.
- Prior coronary artery bypass grafting (CABG) or prior percutaneous coronary intervention (PCI) performed in non-LAD coronary arteries.
- Presentation with ST-segment elevation myocardial infarction (STEMI).
- Discontinuation of prescribed medical therapy by patient preference within one year after the index procedure.
- Presence of multiple chronic total occlusions (CTOs) involving more than one coronary artery.
- Significant side branch disease of the LAD requiring two bypass grafts.
Show all 12Show fewer
- Performance of crossover stenting from the LAD into the left main coronary artery during LAD CTO-PCI.
- Treatment of LAD CTO with drug-eluting balloon (DEB) angioplasty without stent implantation.
- Left ventricular ejection fraction (LVEF) less than 30%.
- Presence of severe valvular heart disease (e.g., severe aortic or mitral stenosis or regurgitation).
- Incomplete angiographic or clinical follow-up data.
- Use of mechanical circulatory support devices due to advanced heart failure, including intra-aortic balloon pump (IABP), extracorporeal membrane oxygenation (ECMO), or left ventricular assist device (LVAD).
Trial locations and contacts
1 site in 1 country.
About this study
Official title: Coronary Artery Bypass Surgery Versus Percutaneous Coronary Intervention in Patients With Isolated Chronic Total Occlusion of the Left Anterior Descending Artery: The RITUAL Study
The aim of this study is to compare coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in the treatment of isolated chronic total occlusion (CTO) of the left anterior descending (LAD) artery in terms of short- and mid-term clinical outcomes, myocardial revascularization success, and complication rates.
Read the detailed description
Chronic total occlusion (CTO) represents one of the most challenging subgroups of coronary artery disease and is closely associated with adverse cardiovascular outcomes. Previous studies have demonstrated that patients with CTO experience a higher incidence of major adverse cardiovascular events compared with patients without CTO but with significant coronary artery disease (CAD), even after adjustment for demographic characteristics, clinical parameters, and disease severity. Among these patients, those with unrevascularized CTO constitute the highest-risk group, whereas successful revascularization has been shown to reduce the risk to a level comparable to that of patients without CTO but with significant CAD.
Among CTOs, isolated total occlusion of the left anterior descending (LAD) artery has particular clinical importance due to its critical role in myocardial perfusion. Two main revascularization strategies are currently used in the treatment of isolated LAD CTO: percutaneous coronary intervention (PCI) and single-vessel coronary artery bypass grafting (CABG). In surgical revascularization, the left internal mammary artery (LIMA) is most commonly used, although saphenous vein grafts may be preferred in selected cases.
However, direct comparative data between these two treatment strategies in this specific patient population remain extremely limited. In particular, differences between CTO-PCI and single-vessel CABG with respect to revascularization success, in-hospital events, and early post-discharge outcomes have not been systematically evaluated. In the present study, within the framework of the RITUAL study, the outcomes of CTO-PCI and CABG surgery were compared in patients with isolated LAD CTO.
- Conditions
- Chronic Total Occlusion
- Being tested
- Coronary Artery Bypass Grafting, Percutaneous Coronary Intervention
- Keywords
- Chronic total occlusion, Coronary artery bypass, Percutaneous coronary intervention, left anterior descending artery, isolated LAD CTO
What participants receive
What participants receive. In a randomised study each person is assigned to one group by chance.
Coronary Artery Bypass GraftingProcedure or surgery
Coronary artery bypass graft surgery performed as part of routine clinical care prior to study inclusion.
Percutaneous Coronary InterventionProcedure or surgery
Percutaneous coronary intervention performed as part of routine clinical care prior to study inclusion.
| Study group | Role | What they receive |
|---|---|---|
| Coronary Artery Bypass Grafting (CABG) | Patients with isolated chronic total occlusion of the left anterior descending artery who underwent coronary artery bypass graft surgery. Receives: Procedure: Coronary Artery Bypass Grafting | |
| Percutaneous Coronary Intervention (PCI) | Patients with isolated chronic total occlusion of the left anterior descending artery who underwent percutaneous coronary intervention. Receives: Procedure: Percutaneous Coronary Intervention |
What is being measured
The primary outcome is the main question the study is designed to answer.
Procedural success
Successful completion of coronary revascularization of the left anterior descending artery without in-hospital major adverse cardiac events.
Measured: perioperatively / periprocedurally
Secondary outcomes (1)
Major adverse cardiac events (MACCE) at 3 years
Composite endpoint including all-cause mortality, non-fatal myocardial infarction, cerebrovascular events, and target vessel revascularization within 3 years after the index procedure.
Measured: 3 years
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted28 Jan 2026
- Study start10 Sep 2025
- Primary completion31 Dec 2025
- Study completion15 Jan 2026
Resources
- Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
- Publications (1)Papers the sponsor has linked to this study.
- Other trials for Chronic Total OcclusionStudies of the same condition, open and under way.
- What the trial phases meanHow a treatment moves from first tests in people to approval.
More details
For doctors and researchers: how the study is designed, who runs it, and its registry IDs.
Study design
- Study type
- Observational
- Observational model
- Cohort
- Time perspective
- Retrospective
- Enrolment
- 302 participants (actual)
Sponsor and investigators
- Lead sponsor
- Mersin Medicalpark Hastanesi
- Sponsor type
- University, hospital or other
- Collaborators
- Biruni University, Mersin Training and Research Hospital, Necmettin Erbakan University, Jolimont Hospital, Minneapolis Heart Institute
- Responsible party
- Principal investigator, Sefa Sural, Mersin Medicalpark Hastanesi
- Investigators
- Sefa SURAL, MD, Principal investigator, Toros University
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT07373678
- Sponsor's protocol ID
- MLP-SSURAL-002
- Acronym
- RITUAL
- Status last verified
- Jan 2026
- First submitted
- 17 Jan 2026
- Last updated
- 28 Jan 2026
- Results posted
- No
- Data monitoring committee
- No
- FDA-regulated drug
- No
- FDA-regulated device
- No
- Individual data sharing
- No: Individual participant data will not be shared due to the retrospective design of the study and institutional data privacy policies.
Publications
Sural S, Ungureanu C, Yildirim A, Aslan V, Duzel B, Gurbuz AS, Gormus N, Karaca MK, Ozcaliskan O, Kocas C, Brilakis ES, Gorgulu S. Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention in Isolated Chronic Total Occlusion of the Left Anterior Descending Artery: The RITUAL Study. J Am Heart Assoc. 2026 Sep 29:e051162. doi: 10.1161/JAHA.126.051162. Online ahead of print.
PubMed 42808438
Study at a glance
From the registry record, last updated by the sponsor on 28 Jan 2026. Recruitment status is as the sponsor reported it: confirm with the study team.
- Official title
- Coronary Artery Bypass Surgery Versus Percutaneous Coronary Intervention in Patients With Isolated Chronic Total Occlusion of the Left Anterior Descending Artery: The RITUAL Study
- ClinicalTrials.gov ID
- NCT07373678
- Acronym / sponsor ID
- RITUAL / MLP-SSURAL-002
- Conditions
- Chronic Total Occlusion
- Keywords
- Chronic total occlusion, Coronary artery bypass, Percutaneous coronary intervention, left anterior descending artery, isolated LAD CTO
- Study type
- Observational
- Recruitment status
- Completed
- Enrolment
- 302 participants (actual)
- Lead sponsor
- Mersin Medicalpark HastanesiUniversity, hospital or other
- Collaborators
- Biruni University, Mersin Training and Research Hospital, Necmettin Erbakan University, Jolimont Hospital, Minneapolis Heart Institute
- Study start
- 10 Sep 2025 (actual)
- Primary completion
- 31 Dec 2025 (actual)
- Study completion
- 15 Jan 2026 (actual)
- First posted
- 28 Jan 2026 (actual)
- Results
- Not posted in the source record
Clinical summary
The research question as the sponsor registered it. This describes what the study plans to test, not what it found.
The aim of this study is to compare coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in the treatment of isolated chronic total occlusion (CTO) of the left anterior descending (LAD) artery in terms of short- and mid-term clinical outcomes, myocardial revascularization success, and complication rates.
Detailed description
Chronic total occlusion (CTO) represents one of the most challenging subgroups of coronary artery disease and is closely associated with adverse cardiovascular outcomes. Previous studies have demonstrated that patients with CTO experience a higher incidence of major adverse cardiovascular events compared with patients without CTO but with significant coronary artery disease (CAD), even after adjustment for demographic characteristics, clinical parameters, and disease severity. Among these patients, those with unrevascularized CTO constitute the highest-risk group, whereas successful revascularization has been shown to reduce the risk to a level comparable to that of patients without CTO but with significant CAD.
Among CTOs, isolated total occlusion of the left anterior descending (LAD) artery has particular clinical importance due to its critical role in myocardial perfusion. Two main revascularization strategies are currently used in the treatment of isolated LAD CTO: percutaneous coronary intervention (PCI) and single-vessel coronary artery bypass grafting (CABG). In surgical revascularization, the left internal mammary artery (LIMA) is most commonly used, although saphenous vein grafts may be preferred in selected cases.
However, direct comparative data between these two treatment strategies in this specific patient population remain extremely limited. In particular, differences between CTO-PCI and single-vessel CABG with respect to revascularization success, in-hospital events, and early post-discharge outcomes have not been systematically evaluated. In the present study, within the framework of the RITUAL study, the outcomes of CTO-PCI and CABG surgery were compared in patients with isolated LAD CTO.
Study design
- Observational model
- Cohort
- Time perspective
- Retrospective
- Number of arms
- 2
| Arm | Type | Receives |
|---|---|---|
| Coronary Artery Bypass Grafting (CABG) | – | Procedure: Coronary Artery Bypass GraftingPatients with isolated chronic total occlusion of the left anterior descending artery who underwent coronary artery bypass graft surgery. |
| Percutaneous Coronary Intervention (PCI) | – | Procedure: Percutaneous Coronary InterventionPatients with isolated chronic total occlusion of the left anterior descending artery who underwent percutaneous coronary intervention. |
Who may qualify
- Ages
- 18 years and older
- Sex
- All
- Healthy volunteers
- Not accepted
- Age groups
- Adult, Older adult
- Study population
- The study population consists of adult patients aged 18 years or older with isolated chronic total occlusion (CTO) of the left anterior descending (LAD) coronary artery who underwent coronary revascularization with either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) as part of routine clinical care. Isolated LAD CTO was defined as a de novo or in-stent total occlusion confined to the LAD artery, without significant coronary artery disease (≥50% stenosis) in other major epicardial coronary arteries. Patients with prior coronary revascularization, multiple CTOs, severe left ventricular dysfunction, or incomplete follow-up data were excluded.
Key inclusion criteria (5 listed)
- Age 18 years or older at the time of the index procedure.
- Diagnosis of isolated chronic total occlusion (CTO) of the left anterior descending (LAD) coronary artery.
- Isolated LAD CTO defined as a de novo or in-stent total occlusion confined to the LAD artery, without significant coronary artery disease (defined as ≥50% stenosis) in other major epicardial coronary arteries, including the left circumflex (LCx), right coronary artery (RCA), or major side branches.
- No prior percutaneous coronary intervention (PCI) performed in non-LAD coronary arteries.
- Patients who underwent coronary revascularization with either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) for isolated LAD CTO.
Key exclusion criteria (12 listed)
- History of malignancy or active malignant disease at the time of the index procedure.
- Prior coronary artery bypass grafting (CABG) or prior percutaneous coronary intervention (PCI) performed in non-LAD coronary arteries.
- Presentation with ST-segment elevation myocardial infarction (STEMI).
- Discontinuation of prescribed medical therapy by patient preference within one year after the index procedure.
- Presence of multiple chronic total occlusions (CTOs) involving more than one coronary artery.
Eligibility is decided by the study team after screening; this overview does not establish that a patient qualifies. Full inclusion and exclusion criteria.
Interventions
| Intervention | Type | Arms |
|---|---|---|
| Coronary Artery Bypass GraftingCoronary artery bypass graft surgery performed as part of routine clinical care prior to study inclusion. | Procedure or surgery | Coronary Artery Bypass Grafting (CABG) |
| Percutaneous Coronary InterventionPercutaneous coronary intervention performed as part of routine clinical care prior to study inclusion. | Procedure or surgery | Percutaneous Coronary Intervention (PCI) |
Primary outcome
Procedural success
Time frame: perioperatively / periprocedurally
Successful completion of coronary revascularization of the left anterior descending artery without in-hospital major adverse cardiac events.
1 secondary outcome
Major adverse cardiac events (MACCE) at 3 years
Time frame: 3 years
Results and safety
The study is completed, but results are not available in the source record. That does not mean the treatment did or did not work.
Research links
- Official record on ClinicalTrials.govLast updated by the sponsor 28 Jan 2026.
- Derived from this study: PubMed 42808438Sural S, Ungureanu C, Yildirim A, Aslan V, Duzel B, Gurbuz AS, Gormus N, Karaca MK, Ozcaliskan O, Kocas C, Brilakis ES, Gorgulu S. Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention in Isolated Chronic Total Occlusion of the Left Anterior Descending Artery: The RITUAL Study. J Am Heart Assoc. 2026 Sep 29:e051162. doi: 10.1161/JAHA.126.051162. Online ahead of print.
- Individual participant dataSharing planned: No. Individual participant data will not be shared due to the retrospective design of the study and institutional data privacy policies.
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Referral and contact
AzTrials does not enrol participants or take referrals. Contact the study team or a site listed below; they decide who can take part. This study is not recruiting at the moment.
Sefa SURAL, MD principal investigator
Toros University
1 site in 1 country: see every site and its status.
Questions about this trial
What is this clinical trial studying?
An observational study of Chronic Total Occlusion, run by Mersin Medicalpark Hastanesi at 1 site in Turkey (Türkiye).
The full registered description is in the About this study section and the official record.
Who may be eligible to take part?
The sponsor lists 5 inclusion and 12 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.
Is this clinical trial currently recruiting?
The record says: finished, as of the sponsor's last update on 28 Jan 2026. Status can change between updates, so confirm with the study contact before making plans.
Where is the study taking place?
The record lists 1 site in Turkey (Türkiye). Whether a site is taking part right now should be confirmed with that site. See every site.
What are the possible benefits and risks?
They depend on the study and the treatment, and no study can promise a benefit. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.
Are results available for this study?
The study is completed, but results are not available in the source record. That does not mean the treatment did or did not work.
How can a doctor refer a patient or contact the research team?
The record lists no contact. The official record names the sponsor, who can be asked directly. AzTrials does not enrol participants or take referrals.
What does the primary outcome measure?
Procedural success (time frame: perioperatively / periprocedurally). It is what the study was designed to measure, not a finding.
Where can I read the original study information?
On the ClinicalTrials.gov record for NCT07373678, which also lists 1 linked publication.
Does a listing mean the treatment is approved or proven to work?
No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.
How often is this information updated?
AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 28 Jan 2026.