This study sought to perform a systematic review and meta-analysis of studies comparing complete revascularization (CR) versus incomplete revascularization (IR) in patients with multivessel coronary ...artery disease.
There are conflicting data regarding the benefits of CR in patients with multivessel coronary artery disease.
We identified observational studies and subgroup analysis of randomized clinical trials (RCT) published in PubMed from 1970 through September 2012 using the following keywords: "percutaneous coronary intervention" (PCI); "coronary artery bypass graft" (CABG); "complete revascularization"; and "incomplete revascularization." Main outcome measures were total mortality, myocardial infarction, and repeat revascularization procedures.
We identified 35 studies including 89,883 patients, of whom 45,417 (50.5%) received CR and 44,466 (49.5%) received IR. IR was more common after PCI than after CABG (56% vs. 25%; p < 0.001). Relative to IR, CR was associated with lower long-term mortality (risk ratio RR: 0.71, 95% confidence interval CI: 0.65 to 0.77; p < 0.001), myocardial infarction (RR: 0.78, 95% CI: 0.68 to 0.90; p = 0.001), and repeat coronary revascularization (RR: 0.74, 95% CI: 0.65 to 0.83; p < 0.001). The mortality benefit associated with CR was consistent across studies irrespective of revascularization modality (CABG: RR: 0.70, 95% CI: 0.61 to 0.80; p < 0.001; and PCI: RR: 0.72, 95% CI: 0.64 to 0.81; p < 0.001) and definition of CR (anatomic definition: RR: 0.73, 95% CI: 0.67 to 0.79; p < 0.001; and nonanatomic definition: RR: 0.57, 95% CI: 0.36 to 0.89; p = 0.014).
CR is achieved more commonly with CABG than with PCI. Among patients with multivessel coronary artery disease, CR may be the optimal revascularization strategy.
...a single arterial access was used in most cases in this series, yet dual arterial access is recommended for most CTO PCIs (unless there are no contralateral collaterals) to optimize the efficacy ...and safety of the procedure.12,13 Third, the incidence of radial artery occlusion was not assessed. Both dTRA and TUA were associated with procedural outcomes equivalent to those of proximal TRA, supporting their use in CTO PCI.Declaration of Competing Interest Dr. Brilakis declares consulting/speaker honoraria from Abbott Vascular, American Heart Association (associate editor Circulation), Amgen, Asahi Intecc, Biotronik, Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), CSI, Elsevier, and GE Healthcare (Little Chalfont, United Kingdom), IMDS, Medicure, Medtronic, Siemens, and Teleflex; research support: Studies Technical success (dTRA vs TRA) Procedural success (dTRA vs TRA) In-hospital MACCE (dTRA vs TRA) Vascular complications (dTRA vs TRA) Poletti et al (Present study) 92% vs 95% (p = 0.50) 92% vs 94% (p = 0.70) 4% vs 1.9% (p = 0.60) 2.0% vs 2.9% (p >0.90) Lin et al (2021) 94%* 94%* 0.7%* 3.7%* Nikolakopoulos et al (2021) 91% vs 86% (p = 0.014) 91% vs 84% (p = 0.05) 0.8% vs 2.4% (p = 0.26) 1.3% vs 2.3% (p = 0.09) Achim et al (2022) 91% vs 83% (p = 0.161) 88% vs 80% (p = 0.664) 3.8% vs 4.3%† (p = 1) 3.8% vs 5.1% (p = 0.820) Table 1 Comparison of distal with proximal radial access for CTO PCI
Successful percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs) has been associated with clinical benefit. There are no randomized controlled trials on long-term clinical ...outcomes after CTO PCI, limiting the available evidence to observational cohort studies. We sought to perform a weighted meta-analysis of the long-term outcomes of successful versus failed CTO PCI. A total of 25 studies, published from 1990 to 2014, with 28,486 patients (29,315 CTO PCI procedures) were included. We analyzed data on mortality, subsequent coronary artery bypass grafting (CABG), myocardial infarction, major adverse cardiac events, angina pectoris, stroke, and target vessel revascularization using random-effects models. Procedural success was 71% (range 51% to 87%). During a weighted mean follow-up of 3.11 years, compared with unsuccessful, successful CTO PCI was associated with lower mortality (odds ratio OR 0.52, 95% confidence interval CI 0.43 to 0.63), less residual angina (OR 0.38, 95% CI 0.24 to 0.60), lower risk for stroke (OR 0.72, 95% CI 0.60 to 0.88), less need for subsequent coronary artery bypass grafting (OR 0.18, 95% CI 0.14 to 0.22), and lower risk for major adverse cardiac events (0.59, 95% CI 0.44 to 0.79). There was no difference in the incidence of target vessel revascularization (OR 0.66, 95% CI 0.36 to 1.23) or myocardial infarction (OR 0.73, 95% CI 0.52 to 1.03). Outcomes were similar in patients who underwent balloon angioplasty only or stenting with bare metal or drug-eluting stents. Compared with failed procedures, successful CTO PCIs are associated with a lower risk of death, stroke, and coronary artery bypass grafting and less recurrent angina pectoris.
Contrast-induced acute kidney injury (CI-AKI) is a potentially serious complication following coronary angiography and percutaneous coronary intervention (PCI). The incidence of CI-AKI is ...particularly high in patients with advanced chronic kidney disease (defined as an estimated glomerular filtration rate <30 ml/min/1.73 m2). Although much effort has been dedicated to the identification and implementation of preventive measures for this complication at the pre-intervention stage, much less has been investigated on the procedural strategies and techniques to decrease the risk of CI-AKI during PCI. The mainstay of such approaches relies on the minimization of contrast volume by means of specific strategies or dedicated devices. Invasive imaging, such as intravascular ultrasound or non–contrast-based optical coherence tomography, is another pillar of any ultra-low-contrast-volume PCI protocol. Finally, an array of miscellaneous ancillary measures can be implemented to decrease the risk of CI-AKI, which includes the use of radial access, remote ischemic conditioning, and hemodynamic support in high-risk patients. The present review analyzes the technical aspects as well as the scientific evidence supporting these novel techniques, with the goal to improve the outcomes of patients at high risk for CI-AKI undergoing PCI.
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•The incidence of CI-AKI is particularly high (>25%) in patients with advanced CKD undergoing PCI, and has been associated with increased risk for in-hospital dialysis and mortality.•Implementing contrast-sparing protocols may reduce the risk for CI-AKI in patients with advanced CKD undergoing coronary angiography and PCI.•Additional components of an ultra-low-contrast-volume PCI protocol include strong reliance on intravascular imaging, device-based interventions, and ancillary measures.•Prospective (ideally randomized) studies should evaluate whether the implementation of the procedural recommendations discussed herein can lead to decreased rates of CI-AKI, need for dialysis, and mortality in high-risk patients undergoing PCI.
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