Prior PCI does little to affect CABG outcomes

Despite past research suggesting a history of percutaneous coronary intervention (PCI) could complicate coronary artery bypass grafting (CABG) outcomes, a study published in the Journal of the American Heart Association Oct. 16 reported prior PCI has little to do with how a patient recovers from subsequent surgeries.

“Multiple prior PCI procedures and multiple treated vessels could hypothetically be associated with worse outcome, but scarce data exist to substantiate this,” first author Fausto Biancari, MD, PhD, and co-authors wrote in JAHA. Biancari et al. studied more than 6,500 patients from the E-CABG registry in an effort to assess the risk a previous PCI patient might face in future interventions.

In 2008, the overall prevalence of prior PCI in patients undergoing isolated CABG was 21.3 percent, as per the Society of Thoracic Surgeons’ records. A decade later it’s risen to 28.9 percent, and Biancari’s team said the number is continuing to climb. Still, reports on the subject have conflicted with one another for decades.

Biancari’s team recruited 6,563 patients for their study, 18 percent of whom had at least one PCI on the books. The remainder of patients had no history of PCI.

One previous PCI was performed in 11.6 percent of the study population, while 4.4 percent and 2.1 percent reported two or at least three past PCIs, respectively. PCI of a single main coronary vessel was performed in 11.3 percent of patients, two major vessels were treated in 4.9 percent and three major vessels were treated in 1.6 percent.

After multivariable analysis, Biancari and co-authors said rates of early mortality and other adverse outcomes were similar between PCI and non-PCI patients. Adjusted hospital and 30-day mortality rates were as follows:

  • 1.8 percent in patients without a history of PCI

  • 1.9 percent in patients with one prior PCI

  • 1.4 percent in patients with two prior PCIs

  • 2.5 percent in patients with at least three prior PCIs

The numbers showed an increase in adverse events in those who’d undergone previous intervention, but none of the figures reached statistical significance.

In a related editorial, Ravi S. Kahlon, MD, and Ehrin J. Armstrong, MD, MSc, said Biancari et al.’s study was “well-conducted,” but it lacked in ways that beg for additional follow-up. One such limitation was the study’s exclusion criteria, which Kahlon and Armstrong said ignored a substantial portion of patients who undergo PCI within a month of CABG. 

“This study confirms earlier reports that successful prior stenting does not add to significant in-hospital/30-day mortality in patients with an intermediate SYNTAX score when subsequently undergoing isolated CABG,” wrote Kahlon and Armstrong, both of the University of Colorado School of Medicine in Denver. “Longer-term follow-up of this and other cohorts will help to further inform future clinical decision-making in this increasingly common group of patients.”

The pair suggested physicians pay close attention to individual patients’ risk for diabetes, left ventricular dysfunction, atrial fibrillation and valvular abnormalities in addition to calculating a risk score for them. 

“In our opinion, a patient-centered approach and a practical understanding of the current literature is critical when referring stable patients with prior PCI for CABG,” they wrote. “A well-informed patient and their caregivers who have been informed of the risks and benefits of CABG versus PCI with regards to periprocedural and long-term morbidity and outcome is always a sound initial approach to management.”