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Incidence and predictors of incomplete revascularization in a contemporary cohort
Stephen W Waldo1, Farhad Abtahian, Kevin F Kennedy
1aDepartment of Medicine, VA Eastern Colorado Health Care System, Denver, Colorado bDepartment of Medicine, Rochester General Hospital, Rochester, New York cSaint Luke's Mid-America Heart Institute, Kansas City, Missouri dDepartment of Medicine, Cardiovascular Division, Brigham and Women's Hospital eDepartment of Quality, Safety, and Value, Partners Healthcare fDepartment of Medicine, Division of Cardiology, Beth Israel Deaconess, Boston, Massachusetts, USA.
Insights
Complete percutaneous coronary intervention (PCI) for multivessel disease is uncommon, often limited by chronic total occlusions. Advancements in PCI techniques may improve rates of complete revascularization in the future.
Area of Science:
- Interventional Cardiology
- Cardiovascular Medicine
- Medical Technology
Background:
- Complete revascularization after bypass grafting improves mortality.
- Complete revascularization via percutaneous coronary intervention (PCI) for multivessel disease is often not achieved.
- Understanding limitations to complete PCI is crucial for optimizing patient outcomes.
Purpose of the Study:
- To evaluate clinical and anatomic factors limiting complete revascularization in patients with multivessel coronary artery disease undergoing PCI.
- To identify reasons why complete revascularization is not achieved in contemporary practice.
Main Methods:
- Retrospective review of 978 patients with multivessel coronary artery disease undergoing nonemergent PCI at two academic centers (2009-2012).
- Complete revascularization status determined by reviewing electronic medical records and coronary angiograms.
- Reasons for incomplete revascularization analyzed based on clinical and angiographic findings.
Main Results:
- Only 27% of patients achieved complete revascularization.
- Key limitations included chronic total occlusions (54%), treatment of only the culprit lesion (24%), and disease in small vessels (24%).
- Chronic total occlusions significantly reduced the odds of achieving complete revascularization (aOR 0.18).
Conclusions:
- Complete percutaneous revascularization is infrequently achieved in multivessel coronary artery disease.
- Chronic total occlusions and treating only the culprit lesion are major barriers.
- Future advancements in PCI techniques, particularly for chronic total occlusions, may increase the rate of complete revascularization.
Objectives:
Complete coronary revascularization has been associated with improved mortality among patients undergoing surgical bypass grafting. A similar evaluation among patients undergoing percutaneous coronary intervention (PCI) for multivessel disease has produced largely concordant results, although complete percutaneous revascularization is often not achieved in this population. The present study sought to evaluate the clinical and anatomic limitations to complete revascularization among contemporary patients undergoing percutaneous revascularization for multivessel coronary artery disease.
Methods:
All patients undergoing nonemergent PCI for unprotected left main or multivessel coronary artery disease were identified at two academic medical centers from 2009 to 2012. Complete revascularization was determined through a review of the electronic medical records and corresponding coronary angiograms. The underlying reasons that precluded complete revascularization were then derived from a review of the clinical and angiographic findings.
Results:
Among 978 patients with multivessel coronary artery disease, 267 (27%) underwent complete percutaneous coronary revascularization. Factors that prevented complete revascularization included chronic total occlusions (54%), treatment limited to the culprit lesion (24%), or persistent disease in small nondominant vessels (24%). After multivariable adjustment, the presence of a chronic total occlusion was associated with significantly reduced odds of receiving complete revascularization (adjusted odds ratio: 0.18, 95% confidence interval: 0.12-0.27).
Conclusion:
Complete percutaneous revascularization is uncommon and is hindered by the presence of chronic total occlusions or isolated treatment of an angiographic culprit lesion. Evolving interventional techniques enabling treatment of chronic total occlusions may increase the prevalence of complete percutaneous revascularization in the future.
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