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.
PDF
