Incomplete Revascularization Does Not Mean the Same Thing for All Patients

Several studies show that patients with multivessel lesions who undergo angioplasty with incomplete revascularization experience more events, including higher mortality, than a cohort of patients who have undergone complete revascularization.

In most cases, the analysis was dichotomic (complete vs. incomplete revascularization), but more recent studies show that there may be a gradient, a continuum, in which not all patients with incomplete revascularization are equal. The study herein discussed went beyond this and looked for specific vessels that seem to be more important, and the stenosis threshold from which different outcomes might be expected.

Read also: “Five-Year Outcomes for Appendage Closure”.

New York’s angioplasty database was used to examine mortality (mean follow-up, 3.4 years) as a function of the number of vessels that were not revascularized, the stenosis in those vessels, and how compromised the proximal left anterior descending artery was after controlling for other factors associated with mortality.

This study included 41,639 patients with multivessel disease who underwent angioplasty between 2010 and 2012.

Incomplete revascularization was very common (78% among patients admitted with ST-segment elevation myocardial infarction and 71% among patients with non-ST-segment elevation acute coronary syndromes and stable coronary disease). Patients with incomplete revascularization in a vessel with at least 90% stenosis were at higher risk than other patients with incomplete revascularization. This was different for patients with ST-elevation myocardial infarction (17.18% vs. 12.86%; hazard ratio [HR]: 1.16; 95% confidence interval [CI]: 0.99-1.37), but significant among all other patients (17.71% vs. 12.96%; HR: 1.15; 95% CI: 1.07-1.24).

Read also: “New FFR Measuring Device to Guide Coronary Revascularization with Our Preferred Wire”.

Similarly, patients with incomplete revascularization in 2 or more vessels had higher mortality than patients with complete revascularization and patients with incomplete revascularization in only one vessel.

Results among patients with no revascularization of the proximal left anterior descending artery vessel were anything but surprising: they had higher mortality than all other patients with incomplete revascularization, regardless of their clinical syndrome.

More than 20% of all patients who underwent angioplasty had incomplete revascularization of 2 or more vessels and more than 30% had at least one lesion with more than 90% stenosis.

Conclusion

Patients with incomplete revascularization are at higher risk of mortality in the following cases:

• If they have a lesion with more than 90% stenosis that has not been revascularized.
• If 2 or more vessels are left without revascularization.
• If the vessel without revascularization is the proximal anterior descending artery.

Editorial

The first results of this database analysis showed that in an extremely high percentage of patients with angioplasty and incomplete revascularization (96%) physicians directly did not attempt complete revascularization.

This is important information, since it allows us to reduce drastically the risk for these patients. Now, we have a better idea of which lesions we should unavoidably revascularize (or, at least, make an attempt).

Original title: Association of Coronary Vessel Characteristics with Outcome in Patients with Percutaneous Coronary Interventions with Incomplete Revascularization.

Reference: Edward L. Hannan et al. JAMA Cardiol. 2017 Dec 27. Epub ahead of print.

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