Original title: The Negative Impact of Incomplete Angiographic Revascularization on Clinical Outcomes and Its Association With Total Occlusions. The SYNTAX (Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery) Trial. Reference: Vasim Farooq et al. J Am Coll Cardiol 2013;61:282–94
In patients with complex coronary artery disease who underwent coronary artery bypass surgery, (CABG), or percutaneous transluminal coronary angioplasty, (PTCA), the long-term prognosis of complete versus incomplete revascularization is unclear.
In fact, recent studies suggest that complete revascularization when receiving CABG does not significantly improve the long-term prognosis. The aim of this study was to report the long-term clinical impact, (4 years), of the complete or incomplete angiography revascularization in all patients, “all-comers”, of the SYNTAX study, (both randomized and those included in the record of CABG and PTCA). With a total of 2,636 patients, complete revascularization was achieved in 52.8% of those receiving PTCA, (n = 1095), and 66.9% of those receiving CABG, (n = 1541).
Patients with incomplete revascularization had a greater anatomical complexity, (high SYNTAX score and total occlusions), more comorbidities, (higher EuroSCORE), and a lower incidence of injury to the left coronary trunk. In both branches incomplete revascularization, (compared to complete), was associated with a significant increase in mortality at 4 years, of revascularization, stent thrombosis and major cardiovascular and cerebrovascular events (MACCE). The biggest predictor of incomplete revascularization for PTCA branch were total occlusions and for the CABG branch left dominance. Complete revascularization in patients with total occlusions was associated with lower stent thrombosis at 4 years in the PTCA branch as well as minor occlusion of the bridges in the CABG branch.
Conclusion:
In both branches, angioplasty and surgery, incomplete angiographic revascularization seems to be connected to anatomical complexity and clinical comorbidities. It has a long-term negative impact on all events including mortality.
Editorial Comment:
The results of this post hoc study should be considered as hypothesis but generating, nevertheless, many interesting facts. For example, patients with incomplete revascularization presented high stent thrombosis despite receiving fewer stents and the total length was significantly less treated. This could be explained by a more challenging anatomy with a poor distal bed and severe calcification. In the CABG branch patients with complete revascularization without occlusions had higher occlusions of the bridges that those that had total occlusions. Perhaps the bridges connected to uninjured arteries actually present flow competition and tend to occlude over time. Finally, the concepts of “reasonable” or “acceptable” revascularization are emerging but it is unclear what percentage of ischemic myocardium we can “tolerate” and if angiography should be replaced by the fractional flow reserve, (FFR), to complete the divide of incomplete occlusions.
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