Circ: Ischemia-guided bests angio-guided revascularization
Integrating angiographic complete revascularization into clinical practice after drug-eluting stent (DES) implantation or CABG surgery did not improve long-term outcomes in patients with multivessel coronary disease, according to a study published online May 16 in Circulation. Due to these findings, researchers said that they instead support ischemia-guided revascularization in some instances.

Although previous studies have shown that complete revascularization is associated with better long-term outcomes after PCI or CABG surgery in patients with multivessel coronary disease, oftentimes revascularization is incomplete in patients undergoing PCI with DES due to technical complexity, low ejection fraction and safety concerns, the researchers wrote. “Furthermore, even with CABG, the strategy of incomplete revascularization has occasionally been adopted to reduce operation-related complications, particularly when minimally invasive or off-pump surgery is attempted.”

To better assess the long-term clinical impacts of angiographic complete revascularization compared with incomplete revascularization in patients undergoing PCI with DES, Young-Hak Kim, MD, PhD, of the University of Ulsan College of Medicine, Asan Medical Center in Seoul, South Korea, and colleagues enrolled 1,914 patients with multivessel coronary disease from the Asan Medical Center Multivessel Registry that included patients who underwent DES implantation of CABG surgery between January 2003 and December 2005.

Of the 1,914 patients, 1,400 patients underwent PCI with DES and 514 patients who underwent CABG. Total angiographic revascularization was performed on 917 patients—573 patients in the PCI group and 344 patients in the CABG group.

Patients in the PCI arm who underwent complete revascularization were younger, had greater left ventricular ejection fractions, less prior angioplasty and less extensive coronary disease. These patients were also treated with a greater number of stents.

Complete revascularization-2 (considered diseased segments that were 2.5 mm or greater in diameter) was performed in 1,127 patients: 721 PCI patients and 406 CABG patients. Proximal revascularization assessing the proximal arterial segments was feasible in 1,194 patients—792 PCI patients and 402 CABG patients.

When the researchers subdivided incomplete revascularization to the number of nonrevascularized vessels they found that one-, two- and three-vessel incomplete revascularization occurred in 629 patients, 304 patients and 64 patients, respectively. Multivessel IR took place in 24.6 percent of PCI patients and 4.7 percent of CABG patients.

Kim and colleagues followed patients for a median of 1,800 days. The researchers reported similar MACE and MACCE rates in the complete revascularization and incomplete revascularization groups. However, Kim et al noted that multivessel incomplete revascularization was linked to a higher incidence of MACE and MACCE in both PCI and CABG patients.

While anatomic complete revascularization for all angiographic stenoses did not lead to improved long-term outcomes in either PCI or CABG patients with multivessel disease, multivessel incomplete revascularization was associated with “unfavorable” long-term outcomes.

Because PCI is less invasive it is often the preferred method for patients; however, PCI patients are less likely to achieve complete revascularization, particularly in those with multiple coronary lesions and those with decreased ventricular function.

“The reasons for the discrepancy between our results and those showing an association between complete revascularization and clinical outcomes, particularly after PCI, are not clear. Our lack of association may have been due to our use of definitions of complete revascularization based on detailed angiographic analyses in the core laboratory,” the authors wrote.

“Our finding of a lack of association between complete revascularization and clinical prognosis after CABG was in good agreement with recent clinical studies,” Kim and colleagues noted. The researchers also reported a “borderline significant association between multivessel IR and clinical prognosis.”

Kim et al noted that a limitation of the current study was that it was observational and nonrandomized, which could leave room for bias.

“In conclusion, we found that angiographic complete revascularization, when compared with incomplete revascularization, did not improve long-term clinical outcomes of PCI or CABG. The risks and benefits of revascularization treatment may be balanced by an ischemia-guided revascularization strategy.”