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Updated: Dec 30, 2025
Author Spotlight: Enhancing Coronary Artery Revascularization
Published on: September 15, 2023
Mortality After Repeat Revascularization Following PCI or CABG for Left Main Disease: The EXCEL Trial
Gennaro Giustino1, Patrick W Serruys2, Joseph F Sabik3
1The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York.
Insights
Repeat revascularization after left main coronary artery disease treatment occurred more often with percutaneous coronary intervention (PCI) than coronary artery bypass grafting (CABG). This repeat procedure increased mortality risk for both PCI and CABG patients.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Cardiac Surgery
Background:
- The impact of repeat revascularization on mortality following unprotected left main coronary artery disease (LMCAD) treatment with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) remains unclear.
- Left main coronary artery disease (LMCAD) is a critical condition requiring effective revascularization strategies.
Purpose of the Study:
- To investigate the incidence of repeat revascularization after initial PCI or CABG for LMCAD.
- To determine the impact of repeat revascularization on 3-year mortality in patients with LMCAD.
Main Methods:
- Analysis of patients from the EXCEL trial randomized to PCI or CABG for unprotected LMCAD with low/intermediate SYNTAX scores.
- Assessment of repeat revascularization events and their association with all-cause and cardiovascular mortality using time-varying Cox regression models over 3-year follow-up.
Main Results:
- Repeat revascularization occurred more frequently after PCI (12.9%) compared to CABG (7.6%).
- The need for repeat revascularization was independently associated with a significantly increased risk of 3-year all-cause mortality (aHR: 2.05) and cardiovascular mortality (aHR: 4.22).
- This association between repeat revascularization and mortality risk was consistent regardless of the initial revascularization strategy (PCI or CABG).
Conclusions:
- Repeat revascularization was less frequent after CABG than PCI in the EXCEL trial.
- Repeat revascularization was associated with increased mortality following both PCI and CABG for LMCAD.
- Minimizing the need for repeat revascularization may enhance long-term survival outcomes in LMCAD treatment.
Objectives:
The aim of this study was to investigate the incidence and impact on mortality of repeat revascularization after index percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) for left main coronary artery disease (LMCAD).
Background:
The impact on mortality of the need of repeat revascularization following PCI or CABG in patients with unprotected LMCAD is unknown.
Methods:
All patients with LMCAD and site-assessed low or intermediate SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) scores randomized to PCI (n = 948) or CABG (n = 957) in the EXCEL (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial were included. Repeat revascularization events were adjudicated by an independent clinical events committee. The effect of repeat revascularization on mortality through 3-year follow-up was examined in time-varying Cox regression models.
Results:
During 3-year follow-up, there were 346 repeat revascularization procedures among 185 patients. PCI was associated with higher rates of any repeat revascularization (12.9% vs. 7.6%; hazard ratio: 1.73; 95% confidence interval: 1.28 to 2.33; p = 0.0003). Need for repeat revascularization was independently associated with increased risk for 3-year all-cause mortality (adjusted hazard ratio: 2.05; 95% confidence interval: 1.13 to 3.70; p = 0.02) and cardiovascular mortality (adjusted hazard ratio: 4.22; 95% confidence interval: 2.10 to 8.48; p < 0.0001) consistently after both PCI and CABG (pint = 0.85 for both endpoints). Although target vessel revascularization and target lesion revascularization were both associated with an increased risk for mortality, target vessel non-target lesion revascularization and non-target vessel revascularization were not.
Conclusions:
In the EXCEL trial, repeat revascularization during follow-up was performed less frequently after CABG than PCI and was associated with increased mortality after both procedures. Reducing the need for repeat revascularization may further improve long-term survival after percutaneous or surgical treatment of LMCAD. (EXCEL Clinical Trial; NCT01205776).
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