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Percutaneous transluminal coronary angioplasty failures in patients with multivessel disease. Is there an increased
N Wang1, S R Gundry, G Van Arsdell
1Department of Surgery, Loma Linda University Medical Center, Calif. 92354, USA.
Insights
Percutaneous transluminal coronary angioplasty (PTCA) poses a higher risk for patients with multivessel coronary artery disease. Coronary artery bypass grafting (CABG) may be a safer initial revascularization strategy for specific multivessel disease patient subsets.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
Background:
- A growing trend exists for percutaneous transluminal coronary angioplasty (PTCA) in multivessel coronary artery disease (CAD).
- This study compares outcomes of emergency coronary artery bypass grafting (CABG) between single-vessel and multivessel disease patients.
Purpose of the Study:
- To evaluate the differences in clinical outcomes for patients undergoing emergency CABG, comparing those with single-vessel disease versus multivessel disease.
- To identify risk factors associated with mortality and morbidity in these patient groups.
Main Methods:
- A retrospective review of 57 consecutive patients undergoing emergency first-time CABG.
- Patients were categorized into single-vessel disease (n=28) and multivessel disease (n=29) groups.
- Preoperative characteristics, intraoperative data, and postoperative outcomes were analyzed.
Main Results:
- Multivessel disease patients had higher rates of preoperative shock and required ongoing cardiopulmonary resuscitation (p=0.03).
- Significantly more grafts were placed in multivessel disease patients, leading to longer aortic clamping and cardiopulmonary bypass times (p<0.01).
- Mortality (21% vs 4%, p=0.05) and cardiac (38% vs 14%, p=0.04) and noncardiac morbidity (41% vs 14%, p=0.02) were significantly higher in the multivessel disease group.
Conclusions:
- PTCA failure risk is substantially higher in patients with multivessel CAD.
- For specific multivessel disease subsets, particularly those with preoperative shock, low ejection fraction, or advanced age, CABG is a safer initial revascularization choice compared to PTCA.
Abstract:
In recent years, there has been a nationwide trend toward performing percutaneous transluminal coronary angioplasty in patients with multivessel coronary artery disease. The clinical course of 57 consecutive patients who required emergency first-time coronary artery bypass grafting operations were reviewed to assess for difference in outcome between the 28 patients (49%) with single-vessel disease and the 29 patients (51%) with multivessel disease. The two groups were similar in preoperative characteristics except for a higher proportion of chronic obstructive pulmonary disease in the patients with multivessel disease (p = 0.03). Twice as many patients with multivessel disease were in shock (single-vessel disease = 4 [14%], multivessel disease = 8 [28%], p = not significant) en route to the operating room and significantly more patients with multivessel disease required on-going cardiopulmonary resuscitation (single-vessel disease = 0 [0%], multivessel disease = 5 [17%], p = 0.03). Significantly more coronary artery bypass grafts were placed in the patients with multivessel disease (single-vessel disease = 1.5 +/- 0.6, multivessel disease = 2.9 +/- 0.7, p < 0.01), which required longer aortic clamping time (p = 0.02) and cardiopulmonary bypass time (p < 0.01). There were seven postoperative deaths; all but one occurred in patients with multivessel disease (single-vessel disease = 1 [4%], multivessel disease = 6 [21%], p = 0.05). According to multivariate analysis, incremental risk factors of mortality were preoperative shock (p < 0.01), urgent or emergency percutaneous transluminal coronary angioplasty (p = 0.06), and multivessel disease (p = 0.12). Despite a similar incidence of myocardial infarction (single-vessel disease = 8 [29%], multivessel disease = 12 [41%], p = not significant), patients with multivessel disease had a higher incidence of cardiac morbidity (single-vessel disease = 4 [14%], multivessel disease = 11 [38%], p = 0.04) and noncardiac morbidity (single-vessel disease = 4 [14%], multivessel disease = 12 [41%], p = 0.02). By multivariate analysis, incremental risk factors of morbidity were preoperative shock (p < 0.01), multivessel disease (p = 0.02), and ejection fraction < 50% (p = 0.07). In the subset of patients with multivessel disease, preoperative shock, ejection fraction < 50, and an age of 60 years or greater were associated with higher morbidity and mortality. In conclusion, the risk of percutaneous transluminal coronary angioplasty failure is considerably higher in patients with multivessel disease. In certain subsets of patients with multivessel disease, coronary artery bypass grafting would be a safer procedure when compared with percutaneous transluminal coronary angioplasty for initial myocardial revascularization.