Role of Technical Feasibility

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Apart from the extent and distribution of coronary artery disease, the probability of achieving complete revascularization is an important criterion in choosing the most appropriate revascularization strategy.

In CABG, a number of studies have demonstrated that patients who achieve complete revascularization have better long-term outcomes than those with incomplete revascularization.30 The same is also true for PCI. Several studies of the pre-stent era confirmed better long-term outcomes after complete versus incomplete revascularization.31,32 Reasons for not treating all diseased vessels may include technical obstacles such as heavy calcification, tortuous vessels, or chronic total occlusions; the presence of serious concomitant disease; or the intention to treat only the "culprit lesion" that is thought to be responsible for the patient's symptoms.

A recent analysis of 21,945 stent patients from New York State's Percutaneous Coronary Interventions Reporting System assessed the issue of incomplete revascularization with current practices of coronary revascularization. A follow-up period of 3 years was reported.33 In this registry, 68.9% of the stented patients were incompletely revascularized. After adjustment for comorbidities and other baseline characteristics associated with increased risk, incompletely revascularized patients were significantly more likely to die at any time than completely revascularized patients (adjusted hazard ratio [HR] =

1.15; 95% CI: 1.01 to 1.30). The risk associated with incomplete revascularization was higher the greater the number of vessels that were not revascularized, and it was higher with nonrevascularized chronic total occlusions than with nonrevascularized subtotal stenoses. Incompletely revascularized patients with total occlusions and two or more nonrevascular-ized vessels were at the highest risk compared with completely revascularized patients (HR = 1.36; 95% CI: 1.12 to 1.66) (Fig. 6-4).

Given the major impact of the extent of revascu-larization on long-term survival, consideration must be given to the likelihood of achieving complete revascularization. If PCI is unlikely to achieve complete revascularization, surgery may offer better prospects for revascularization. Yet, this may not always be the case. In some instances, poor target vessels for CABG may be treated by PCI with higher chances of success.

--2+ Vessels IR with no total occlusion

--IR with single total occlusion

--Total occlusion and at least one other vessel IR

--Complete revascularization

--2+ Vessels IR with no total occlusion

--IR with single total occlusion

--Total occlusion and at least one other vessel IR

--Complete revascularization

Years

Figure 6-4. Adjusted survival curves for stenting: three subgroups with incomplete revascularization (IR) versus the group with complete revascularization. (From Hannan EL, Racz M, Holmes DR, et al: Impact of completeness of percutaneous coronary intervention revascularization on long-term outcomes in the stent era. Circulation 2006;113:2406-2412.)

Years

Figure 6-4. Adjusted survival curves for stenting: three subgroups with incomplete revascularization (IR) versus the group with complete revascularization. (From Hannan EL, Racz M, Holmes DR, et al: Impact of completeness of percutaneous coronary intervention revascularization on long-term outcomes in the stent era. Circulation 2006;113:2406-2412.)

From the late 1980s to the early 1990s, several studies were designed, conducted, and reported that compared plain balloon angioplasty with CABG. Among them there were three larger trials, RITA (N = 1011), CABRI (N = 1154), and BARI (N = 1829), and three smaller trials, GABI (N = 358), EAST (N = 392), and the Toulouse monocentric study (N = 152). In each of these trials, survival was similar after PCI and after CABG, as was the incidence of Q-wave MI, but repeat revascularization was more frequently needed after PCI. In a meta-analysis based on data extracted from the literature, however, Hoffman and colleagues showed a significant survival benefit from surgery compared with PCI: 3% absolute at 5 years and 4% absolute at 8 years.34

However, the results of the early studies that antedated the stent era are not reflective of the current practice of coronary revascularization. Since those studies were completed, major advances have been achieved in PCI, CABG surgery, and medical treatment. With respect to PCI, coronary stents, currently implanted in more than 80% of all PCIs, have improved the safety and predictability of PCI, with a dramatic decline in the need for emergency CABG, and have reduced the incidence of restenosis by about 10% absolute, compared with plain balloon angioplasty. Moreover, modern adjunctive antiplatelet therapy has reduced the risk of peri-interventional MI by about one half. As for CABG, several advances such as off-pump surgery, minimally invasive surgical approaches, and, most importantly, the widespread use of arterial conduits up to complete arterial revascularization have been introduced. Moreover, irrespective of the revascularization strategy, patients with coronary artery disease have profited from recognition of the importance of risk factor reduction and of vigorous drug therapy to achieve this goal.

For these reasons, results of randomized trials performed in the pre-stent era cannot be transferred to current practice. This chapter will, therefore, focus on the contemporary studies performed with stents and modern pharmacotherapy.

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