Impact of Completeness of Percutaneous Coronary Intervention Revascularization on Long-Term Outcomes in the Stent Era

Abstract

Background-The importance of completeness of revascularization by percutaneous coronary intervention in patients with multivessel disease is unclear in that there is little information on the impact of incomplete revascularization outside of randomized trials. The objective of this study is to compare long-term mortality and subsequent revascularization for percutaneous coronary intervention patients receiving stents who were completely revascularized (CR) with those who were incompletely revascularized (IR). Methods and Results-Patients from New York State's Percutaneous Coronary Interventions Reporting System were subdivided into patients who were CR and IR. Then subsets of IR patients were contrasted with CR patients. Differences in long-term survival and subsequent revascularization for CR and IR patients were compared after adjustment for differences in preprocedural risk. A total of 68.9% of all stent patients with multivessel disease who were studied were IR, and 30.1% of all patients had total occlusions and/or Ն2 IR vessels. At baseline, the following patients were at higher risk: those who were older and those with more comorbid conditions, worse ejection fraction, and more renal disease and stroke. After adjustment for these baseline differences, IR patients were significantly more likely to die at any time (adjusted hazard ratioϭ1.15; 95% confidence interval, 1.01 to 1.30) than CR patients. IR patients with total occlusions and a total of Ն2 IR vessels were at the highest risk compared with CR patients (hazard ratioϭ1.36; 95% confidence interval, 1.12 to 1.66). Conclusions-IR with stenting is associated with an adverse impact on long-term mortality, and consideration should be given to either achieving CR, opting for surgery, or monitoring percutaneous coronary intervention patients with IR more closely after discharge. (Circulation. 2006;113:2406-2412.)

Differential Clinical Outcomes Between Angiographic Complete Versus Incomplete Coronary Revascularization, According to the Presence of Chronic Kidney Disease in the Drug‐Eluting Stent Era

“…Regarding the clinical relevance of angiographic CR, previous studies have shown conflicting results. Some reports in the pre‐DES era showed the clear benefit of angiographic CR rather than IR, and adverse clinical events related to the residual disease after PCI 3, 4, 5, 6, 7, 8. However, other studies reported unclear benefit of angiographic CR over IR 15, 16, 17.…”

“…Although previous studies suggested that angiographic complete revascularization (CR) was more advantageous than incomplete revascularization (IR) and residual disease was associated with adverse clinical outcome after PCI,3, 4, 5, 6, 7, 8 the evidence regarding the benefit of angiographic CR over IR has been limited in CKD patients with multivessel CAD. Given the increasing prevalence of CKD, it would be an important issue to clarify the safety and efficacy of angiographic CR in this high‐risk population 1, 9.…”

Guidelines on myocardial revascularization

“…Observational studies suggest that a successfully revascularized CTO confers a significant 5-and 10-year survival advantage compared with failed revascularization. A New York State survey showed that incomplete revascularization by PCI leaving untreated CTOs led to higher 3-year mortality [199]. Thus, similar to non-chronically occluded vessels, revascularization of CTO may be considered in the presence of angina or ischaemia S32 Rotablation is recommended for preparation of heavily calcified or severely fibrotic lesions that cannot be crossed by a balloon or adequately dilated before planned stenting.…”

Most Important Outcomes Research Papers on Treatment of Stable Coronary Artery Disease

“…Summary-The importance of complete revascularization among patients with stable multi-vessel coronary artery disease (CAD) is uncertain based on data from registries [24][25][26] and trials. [27][28][29][30] The authors performed a post-hoc analysis to determine the effect of complete revascularization on 10-year survival of patients with stable multi-vessel CAD and preserved left ventricular ejection fraction (EF) who were randomly assigned to percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) in the Second Medicine, Angioplasty, or Surgery Study (MASS II) Trial.…”