Repeat revascularization isn’t a rare occurrence after percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), according to a study of patients with left main coronary artery disease (LMCAD)—but it can raise a person’s risk of cardiovascular death by as much as four times.
The need for repeat revascularization after tricky heart procedures has diminished as coronary stent technologies and pharmacotherapies have improved, Gennaro Giustino, MD, of the Icahn School of Medicine at Mount Sinai, and colleagues wrote in JACC: Cardiovascular Interventions. Lower rates of stent thrombosis mean there’s less demand for repeat revascularization after PCI, and the use of multiple arterial grafts, minimally invasive techniques and better medical therapy have diminished that need after CABG, too.
Still, Giustino and co-authors wrote, stent-related complications can motivate repeat revascularization after PCI, as can the development of new, remote obstructive native coronary lesions. Progression of native vessel disease can drive revascularization after CABG regardless of improved therapies.
“Although often considered a clinical endpoint of lesser importance compared with death, stroke or MI, the need for repeat revascularization is associated with worse quality of life and exposes patients to new hospitalizations and procedural risks,” the authors wrote. “In addition, the need for a repeat procedure after revascularization of the left main coronary artery may be associated with substantial morbidity and mortality given the large amount of subtended myocardium at risk.”
Giustino et al. studied the incidence and impact of repeat revascularization after index PCI or CABG among patients in the EXCEL (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial. A total of 948 patients in the EXCEL study underwent PCI and 957 underwent CABG; all patients presented with LMCAD and had low to intermediate SYNTAX (Synergy Between PCI with Taxus and Cardiac Surgery) scores.
The authors said they noted 346 repeat revascularizations among 185 patients during three years of follow-up. PCI was linked to higher rates of any repeat revascularization—12.9% compared to 7.6% with CABG, consistent with research that’s suggested repeat revascularization is more common after PCI—but the need for repeat revascularization after either procedure was independently associated with a more than twofold increased risk of three-year all-cause mortality and a more than fourfold increased risk of CV death.
Target vessel revascularization and target lesion revascularization were both associated with an increased mortality risk, but target vessel non-target lesion revascularization and non-target vessel revascularization weren’t.
“Our findings in an unprotected LMCAD population suggest that the need for and performance of repeat revascularization procedures have prognostic implications, the magnitude of which depends on its indication and type of repeat revascularization,” Giustino and colleagues said, noting that the lower rate of repeat revascularization after CABG may be one factor contributing to the favorable long-term prognosis of surgical revascularization seen in some other trials.
“It is also plausible that measures to reduce repeat revascularization, including improved drug-eluting stents and implantation techniques, use of pan-arterial bypass grafting and aggressive risk factor control with optimal medical therapy may improve prognosis after both PCI and CABG.”