Impact of prior coronary artery bypass graft surgery on chronic total occlusion revascularization: insights from a multicentre US registry

Selected in HEART by G.G. Toth

References

Authors

Tesfaldet T Michael, Dimitri Karmpaliotis, Emmanouil S Brilakis, Shuaib M Abdullah, Ben L Kirkland, Katrina L Mishoe, Nicholas Lembo, Anna Kalynych, Harold Carlson, Subhash Banerjee, William Lombardi, David E Kandzari

Reference

Heart 2013;99:1515-1518

Published

October 2013

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My Comment

Background

Presence of chronic total coronary occlusion (CTO) is known to be frequent among patients with prior CABG surgery. Years after surgery patients develop often new onset of anginal symptoms, either due to graft disease or the progression of atherosclerosis in the native coronary system. Considering the increased risk of graft interventions, especially PCI of saphenous graft, percutaneous coronary intervention of native coronary arteries is preferred as strategy among these patients. The study aimed to investigate differences in CTO-PCI procedures between patients with versus without prior CABG.

Study

  • This retrospective registry enrolled 1,363 patients, who underwent CTO PCI in three US centers between January 2006 and November 2011. Among them 508 patients had prior CABG. All the procedures were performed by experienced operators.
  • Technical success was defined as successful recanalization with <50% residual diameter stenosis and final TIMI III flow. Procedural success was defined as technical success and no in-hospital MACE. MACE was defined as Q wave myocardial infarction, urgent repeat target vessel revascularization, tamponade, or all-cause death.

Results

  • Technical and procedural success rates among the entire study population were 85.5% and 84.2%, respectively. Technical (79.7% vs 88.3%, p<0.001, respectively) and procedural success rates (78.1 vs 87.2, p<0.001, respectively) were reported to be lower among patients with prior CABG versus without prior CABG.
  • Retrograde approach to CTO crossing was more frequently used among patients with prior CABG (47.6% vs 27.1%, p<0.001).
  • In univariate analysis, prior CABG, older age and target CTO vessel in the right coronary artery were associated with failed CTO PCI attempt.
  •  In multivariable analysis, prior CABG (OR 0.49, 95% CI 0.35 to 0.70, p<0.001), male gender (OR=0.51, 95% CI 0.28 to 0.87, p=0.012) and years since initiation of CTO PCI at each centre (OR=1.52 per 1 year increase, 95% CI 1.36 to 1.70, p<0.001=0.012) remained associated with technical success.

My comments

With the development of interventional techniques operators are facing more and more complicated anatomies, such as complex CTO cases. Even though, as authors reported, in hands of experienced operators CTOs can be treated with outstanding success rate, the results of patients with prior CABG is significantly worse compared to patients without previous CABG. However detailed description of the complexity of anatomy in the two groups was not provided in the present work, therefore the influence of other factors cannot be clearly evaluated.

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