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Canadian Journal of Cardiology

Long-Term Outcomes of Percutaneous Coronary Intervention for Chronic Total Occlusion in Patients Who Have Undergone Coronary Artery Bypass Grafting vs Those Who Have Not

Published:December 26, 2017DOI:https://doi.org/10.1016/j.cjca.2017.12.016

      Abstract

      Background

      We aimed to investigate the procedural and long-term outcomes of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) in patients who had undergone previous coronary artery bypass grafting (CABG) vs those who had not, and to evaluate the role of the Registry of CrossBoss and Hybrid procedures in France, the Netherlands, Belgium, and United Kingdom (RECHARGE) score in predicting acute and long-term outcomes.

      Methods

      We compiled a multicentre registry of consecutive patients undergoing CTO PCI at 7 centres between January 2009 and April 2017. The primary end point was target-vessel failure (TVF), a composite of cardiac death, target-vessel myocardial infarction, and target-vessel revascularization on follow-up.

      Results

      Overall, 2058 patients were included (patients who underwent CABG, n = 401; CABG-naïve patients, n = 1657). Patients who had undergone CABG were older and had a higher prevalence of comorbidities and higher occlusion complexity (RECHARGE score, 3.6 ± 1.3 vs 1.8 ± 1.2; P < 0.001). Antegrade dissection/re-entry techniques and the retrograde approach were used more frequently in patients who had undergone CABG. Procedural metrics were worse, and technical (82% vs 88%; P = 0.001) and procedural (81% vs 87%; P = 0.001) success was lower in patients who had undergone CABG. They also experienced a higher rate of major complications (3.7% vs 1.5%; P = 0.004). The RECHARGE score was inversely associated with technical success (P < 0.001). Median follow-up was 377 days (interquartile range, 277-766 days). The 24-month TVF rate was higher in patients who had undergone CABG than in CABG-naïve patients (16.1% vs 9.0%; P < 0.001). On multivariable analysis, the RECHARGE score (hazard ratio, 1.61; P < 0.001) remained an independent predictor of TVF, together with longer total stent length and not using a drug-eluting stent.

      Conclusions

      Compared with CABG-naïve patients, CTO PCI in patients who had undergone CABG shows higher procedural complexity, worse success rates, and higher adjusted risk of TVF on follow-up.

      Résumé

      Introduction

      Notre objectif était d’examiner les résultats chirurgicaux à long terme de l’intervention coronarienne percutanée (ICP) pour une occlusion totale chronique (OTC) chez les patients qui avaient déjà subi un pontage aortocoronarien (PAC) vs ceux qui n’en avaient pas subi, et d’évaluer le rôle du score RECHARGE (Registry of CrossBoss and Hybrid procedures in France, the Netherlands, Belgium, and United Kingdom) dans la prédiction des résultats à court terme et à long terme.

      Méthodes

      Nous avons compilé les données du registre multicentrique de patients consécutifs ayant subi une ICP pour une OTC de 7 centres entre janvier 2009 et avril 2017. Le critère de jugement principal était l’insuffisance du vaisseau cible (IVC), un critère composite de la mort cardiaque, l’infarctus du myocarde en lien avec le vaisseau cible et la revascularisation du vaisseau cible durant le suivi.

      Résultats

      Au total, nous avons regroupé 2058 patients (les patients qui ont subi le PAC, n = 401 ; les patients vierges de tout PAC, n = 1657). Les patients qui avaient subi un PAC étaient plus âgés et avaient une prévalence de comorbidités plus élevée et une complexité d’occlusion plus élevée (score RECHARGE, 3,6 ± 1,3 vs 1 8 ± 1,2 ; P < 0,001). Nous avons utilisé les techniques de dissection/réentrée par voie antérograde et l’approche rétrograde plus fréquemment chez les patients qui avaient subi un PAC. Les mesures de l’intervention étaient moins bonnes, et les taux de réussite de la technique (82 % vs 88 % ; P = 0,001) et de l’intervention (81 % vs 87 % ; P = 0,001) étaient plus faibles chez les patients qui avaient subi un PAC. Ils ont également présenté un taux de complications majeures plus élevé (3,7 % vs 1,5 % ; P = 0,004). Le score RECHARGE était inversement associé à la réussite de la technique (P < 0,001). Le suivi médian était de 377 jours (intervalle interquartile, 277-766 jours). Le taux d’IVC après 24 mois était plus élevé chez les patients qui avaient subi un PAC que chez les patients vierges de tout PAC (16,1 % vs 9,0 % ; P < 0,001). À l’analyse multivariable, le score RECHARGE (rapport de risque, 1,61 ; P < 0,001) demeurait un prédicteur indépendant de l’IVC, conjointement avec la longueur totale plus importante de l’endoprothèse et la non-utilisation de l’endoprothèse médicamentée.

      Conclusions

      Comparativement aux patients vierges de tout PAC, les patients ayant subi un PAC qui subissent une ICP pour une OTC présentent une complexité d’intervention accrue, des taux de réussite plus faibles et un risque ajusté d’IVC plus élevé durant le suivi.
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      Linked Article

      • High Stakes: CTO-PCI in the Post-CABG Patient
        Canadian Journal of CardiologyVol. 34Issue 3
        • Preview
          Chronic total occlusions (CTOs) represent a technically challenging subset of obstructive coronary lesions that are found in approximately one-third of patients with atherosclerotic coronary disease.1 While CTO percutaneous coronary intervention (PCI) techniques and specialized equipment continue to evolve, the so-called “hybrid approach” algorithm has quickly gained favour, offering a success rate of more than 80%.2-8
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