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Canadian Journal of Cardiology

Completeness of Revascularization as a Determinant of Outcome: A Contemporary Review and Clinical Perspectives

  • Osung Kwon
    Affiliations
    Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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  • Duk-Woo Park
    Affiliations
    Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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  • Seung-Jung Park
    Correspondence
    Corresponding author: Dr Seung-Jung Park, Division of Cardiology, Department of Internal Medicine, Asan Medical Center, 388-1 Poongnap-dong, Songpa-gu, Seoul 138-736, South Korea. Tel.: +82-2-3010-4812; fax: +82-2-475-6898.
    Affiliations
    Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Published:January 03, 2019DOI:https://doi.org/10.1016/j.cjca.2018.12.038

      Abstract

      It has been debated whether patients with multivessel coronary artery disease should undergo complete revascularization (CR). The benefit of CR is biologically plausible, and numerous studies and large meta-analyses suggested that CR achievement was associated with a substantial reduction of mortality and future coronary events. In patients with multivessel coronary artery disease, the aim of myocardial revascularization is to minimize residual ischemia. Therefore, CR of all significant coronary lesions has been proposed as the first priority in decision-making for myocardial revascularization between coronary artery bypass grafting and percutaneous coronary intervention (PCI). Reflecting the contemporary practice of ischemia-based revascularization, a physiological/functional approach, such as measurement of fractional flow reserve or instantaneous wave-free ratio, is considered more reasonable and should be encouraged for appropriate CR. In patients who present with acute ST-elevation myocardial infarction, current evidence suggests that an immediate or staged CR strategy might be equivalent or superior to culprit-only revascularization. There is still uncertainty on when and how to perform CR in ST-elevation myocardial infarction patients; comprehensive studies dedicated to this issue are required. Hybrid coronary revascularization includes the advantages of minimally invasive bypass grafting for the left anterior descending artery and PCI for non-left anterior descending arteries and has been proposed as a viable alternative for coronary artery bypass grafting or PCI only for achieving CR. In clinical practice, the extent of revascularization and strategy for CR should be individualized, taking account of different aspects of the patients, lesions, and treating physicians. Collaboration of coronary heart teams would confer balanced decision-making and advanced therapeutic capabilities.

      Résumé

      L’utilité d’une intervention de revascularisation complète chez les patients atteints de coronaropathie pluritronculaire est un sujet qui fait l’objet de débats. Les bienfaits de telles interventions sont plausibles sur le plan biologique. Par ailleurs, de nombreuses études et méta-analyses de grande envergure ont établi un parallèle entre la réalisation d’interventions de revascularisation complète et une réduction considérable de la mortalité et des incidents coronariens subséquents. Chez les patients atteints de coronaropathie pluritronculaire, la revascularisation myocardique vise à réduire au minimum l’ischémie résiduelle. C’est pourquoi la revascularisation complète de toutes les lésions coronariennes d’importance a été proposée comme principale priorité à prendre en compte au moment de décider laquelle des deux interventions que sont le pontage aorto-coronarien et une intervention coronarienne percutanée (ICP) sera réalisée pour revasculariser le myocarde. Reflétant la pratique actuelle en matière de revascularisation motivée par une ischémie, une démarche physiologique et fonctionnelle faisant notamment appel à la mesure de la réserve coronaire fractionnaire (FFR) ou à l’iFR (Instantaneous Wave-Free Ratio) est considérée comme plus valable et doit être encouragée pour pratiquer une revascularisation complète appropriée. Pour ce qui est des patients atteints d’un infarctus du myocarde avec élévation du segment ST, les données probantes actuelles portent à croire qu’une stratégie de revascularisation complète immédiate ou réalisée en plusieurs temps pourrait être équivalente, voire supérieure à une revascularisation visant uniquement les lésions significatives sur le plan fonctionnel. L’incertitude plane toujours à propos du moment propice et de la méthode pour réaliser une revascularisation complète chez ces patients. Il faudra effectuer des études approfondies sur cette question. Une intervention de revascularisation hybride comporte les avantages du pontage aorto-coronarien, une intervention très peu invasive pour l’artère interventriculaire antérieure et ceux de l’ICP pour d’autres artères hormis l’artère interventriculaire antérieure. Elle a en outre été proposée comme solution de rechange viable au pontage aorto-coronarien ou à l’ICP utilisés seuls pour réaliser une revascularisation complète. En pratique clinique, l’étendue de la revascularisation et la stratégie de revascularisation complète choisie doivent être dictées par la situation de chaque patient en tenant compte des différents facteurs qui lui sont propres, de ses lésions et des médecins traitants. La collaboration d’équipes spécialisées en médecine coronarienne serait un atout dans la prise de décisions objectives et ferait bénéficier les patients de compétences thérapeutiques de pointe.
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      References

        • Nagaraja V.
        • Ooi S.Y.
        • Nolan J.
        • et al.
        Impact of incomplete percutaneous revascularization in patients with multivessel coronary artery disease: a systematic review and meta-analysis.
        J Am Heart Assoc. 2016; 5e004598
        • Park D.W.
        • Clare R.M.
        • Schulte P.J.
        • et al.
        Extent, location, and clinical significance of non-infarct-related coronary artery disease among patients with ST-elevation myocardial infarction.
        JAMA. 2014; 312: 2019-2027
        • Buda A.J.
        • Macdonald I.L.
        • Anderson M.J.
        • et al.
        Long-term results following coronary bypass operation. Importance of preoperative actors and complete revascularization.
        J Thorac Cardiovasc Surg. 1981; 82: 383-390
        • Bell M.R.
        • Gersh B.J.
        • Schaff H.V.
        • et al.
        Effect of completeness of revascularization on long-term outcome of patients with three-vessel disease undergoing coronary artery bypass surgery. A report from the Coronary Artery Surgery Study (CASS) Registry.
        Circulation. 1992; 86: 446-457
        • Ijsselmuiden A.J.
        • Ezechiels J.
        • Westendorp I.C.
        • et al.
        Complete versus culprit vessel percutaneous coronary intervention in multivessel disease: a randomized comparison.
        Am Heart J. 2004; 148: 467-474
        • Garcia S.
        • Sandoval Y.
        • Roukoz H.
        • et al.
        Outcomes after complete versus incomplete revascularization of patients with multivessel coronary artery disease: a meta-analysis of 89,883 patients enrolled in randomized clinical trials and observational studies.
        J Am Coll Cardiol. 2013; 62: 1421-1431
        • Tonino P.A.
        • De Bruyne B.
        • Pijls N.H.
        • et al.
        Fractional flow reserve versus angiography for guiding percutaneous coronary intervention.
        N Engl J Med. 2009; 360: 213-224
        • Nam C.W.
        • Mangiacapra F.
        • Entjes R.
        • et al.
        Functional SYNTAX score for risk assessment in multivessel coronary artery disease.
        J Am Coll Cardiol. 2011; 58: 1211-1218
        • Kobayashi Y.
        • Nam C.W.
        • Tonino P.A.
        • et al.
        The prognostic value of residual coronary stenoses after functionally complete revascularization.
        J Am Coll Cardiol. 2016; 67: 1701-1711
        • Li J.
        • Schindler T.H.
        • Qiao S.
        • et al.
        Impact of incomplete revascularization of coronary artery disease on long-term cardiac outcomes. Retrospective comparison of angiographic and myocardial perfusion imaging criteria for completeness.
        J Nucl Cardiol. 2016; 23: 546-555
        • Shaw L.J.
        • Berman D.S.
        • Maron D.J.
        • et al.
        Optimal medical therapy with or without percutaneous coronary intervention to reduce ischemic burden: results from the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial nuclear substudy.
        Circulation. 2008; 117: 1283-1291
        • Zimarino M.
        • Ricci F.
        • Romanello M.
        • et al.
        Complete myocardial revascularization confers a larger clinical benefit when performed with state-of-the-art techniques in high-risk patients with multivessel coronary artery disease: a meta-analysis of randomized and observational studies.
        Catheter Cardiovasc Interv. 2016; 87: 3-12
        • Guandalini G.S.
        • Bangalore S.
        The potential effects of new stent platforms for coronary revascularization in patients with diabetes.
        Can J Cardiol. 2018; 34: 653-664
        • Serruys P.W.
        • Morice M.C.
        • Kappetein A.P.
        • et al.
        Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease.
        N Engl J Med. 2009; 360: 961-972
        • Park S.J.
        • Ahn J.M.
        • Kim Y.H.
        • et al.
        Trial of everolimus-eluting stents or bypass surgery for coronary disease.
        N Engl J Med. 2015; 372: 1204-1212
        • Kapur A.
        • Hall R.J.
        • Malik I.S.
        • et al.
        Randomized comparison of percutaneous coronary intervention with coronary artery bypass grafting in diabetic patients. 1-year results of the CARDia (Coronary Artery Revascularization in Diabetes) trial.
        J Am Coll Cardiol. 2010; 55: 432-440
        • Farkouh M.E.
        • Domanski M.
        • Sleeper L.A.
        • et al.
        Strategies for multivessel revascularization in patients with diabetes.
        N Engl J Med. 2012; 367: 2375-2384
        • Benedetto U.
        • Gaudino M.
        • Ng C.
        • et al.
        Coronary surgery is superior to drug eluting stents in multivessel disease. Systematic review and meta-analysis of contemporary randomized controlled trials.
        Int J Cardiol. 2016; 210: 19-24
        • Lim J.Y.
        • Deo S.V.
        • Kim W.S.
        • et al.
        Drug-eluting stents versus coronary artery bypass grafting in diabetic patients with multi-vessel disease: a meta-analysis.
        Heart Lung Circ. 2014; 23: 717-725
        • Head S.J.
        • Milojevic M.
        • Daemen J.
        • et al.
        Mortality after coronary artery bypass grafting versus percutaneous coronary intervention with stenting for coronary artery disease: a pooled analysis of individual patient data.
        Lancet. 2018; 391: 939-948
        • Ahn J.M.
        • Park D.W.
        • Lee C.W.
        • et al.
        Comparison of stenting versus bypass surgery according to the completeness of revascularization in severe coronary artery disease: patient-level pooled analysis of the SYNTAX, PRECOMBAT, and BEST Trials.
        JACC Cardiovasc Interv. 2017; 10: 1415-1424
        • Fihn S.D.
        • Gardin J.M.
        • Abrams J.
        • et al.
        2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.
        Circulation. 2012; 126: 3097-3137
        • Levine G.N.
        • Bates E.R.
        • Blankenship J.C.
        • et al.
        2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions.
        J Am Coll Cardiol. 2011; 58: e44-e122
        • Neumann F.J.
        • Sousa-Uva M.
        • Ahlsson A.
        • et al.
        2018 ESC/EACTS guidelines on myocardial revascularization.
        Eur Heart J. 2019; 40: 87-165
        • Fefer P.
        • Knudtson M.L.
        • Cheema A.N.
        • et al.
        Current perspectives on coronary chronic total occlusions: the Canadian Multicenter Chronic Total Occlusions Registry.
        J Am Coll Cardiol. 2012; 59: 991-997
        • Sapontis J.
        • Salisbury A.C.
        • Yeh R.W.
        • et al.
        Early procedural and health status outcomes after chronic total occlusion angioplasty: a report from the OPEN-CTO Registry (Outcomes, Patient Health Status, and Efficiency in Chronic Total Occlusion Hybrid Procedures).
        JACC Cardiovasc Interv. 2017; 10: 1523-1534
        • Werner G.S.
        • Martin-Yuste V.
        • Hildick-Smith D.
        • et al.
        A randomized multicentre trial to compare revascularization with optimal medical therapy for the treatment of chronic total coronary occlusions.
        Eur Heart J. 2018; 39: 2484-2493
        • Nombela-Franco L.
        • Mitroi C.D.
        • Fernandez-Lozano I.
        • et al.
        Ventricular arrhythmias among implantable cardioverter-defibrillator recipients for primary prevention: impact of chronic total coronary occlusion (VACTO Primary Study).
        Circ Arrhythm Electrophysiol. 2012; 5: 147-154
        • Jang W.J.
        • Yang J.H.
        • Choi S.H.
        • et al.
        Long-term survival benefit of revascularization compared with medical therapy in patients with coronary chronic total occlusion and well-developed collateral circulation.
        JACC Cardiovasc Interv. 2015; 8: 271-279
        • Tomasello S.D.
        • Boukhris M.
        • Giubilato S.
        • et al.
        Management strategies in patients affected by chronic total occlusions: results from the Italian Registry of Chronic Total Occlusions.
        Eur Heart J. 2015; 36: 3189-3198
        • Christakopoulos G.E.
        • Christopoulos G.
        • Carlino M.
        • et al.
        Meta-analysis of clinical outcomes of patients who underwent percutaneous coronary interventions for chronic total occlusions.
        Am J Cardiol. 2015; 115: 1367-1375
        • Levine G.N.
        • Bates E.R.
        • Blankenship J.C.
        • et al.
        2015 ACC/AHA/SCAI focused update on primary percutaneous coronary intervention for patients with ST-elevation myocardial infarction: an update of the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention and the 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction.
        J Am Coll Cardiol. 2016; 67: 1235-1250
        • O’Gara P.T.
        • Kushner F.G.
        • Ascheim D.D.
        • et al.
        2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
        J Am Coll Cardiol. 2013; 61: e78-e140
        • Wald D.S.
        • Morris J.K.
        • Wald N.J.
        • et al.
        Randomized trial of preventive angioplasty in myocardial infarction.
        N Engl J Med. 2013; 369: 1115-1123
        • Gershlick A.H.
        • Khan J.N.
        • Kelly D.J.
        • et al.
        Randomized trial of complete versus lesion-only revascularization in patients undergoing primary percutaneous coronary intervention for STEMI and multivessel disease: the CvLPRIT trial.
        J Am Coll Cardiol. 2015; 65: 963-972
        • Engstrom T.
        • Kelbaek H.
        • Helqvist S.
        • et al.
        Complete revascularisation versus treatment of the culprit lesion only in patients with ST-segment elevation myocardial infarction and multivessel disease (DANAMI-3-PRIMULTI): an open-label, randomised controlled trial.
        Lancet. 2015; 386: 665-671
        • Smits P.C.
        • Boxma-de Klerk B.M.
        Fractional flow reserve-guided multivessel angioplasty in myocardial infarction.
        N Engl J Med. 2017; 377: 397-398
        • Elgendy I.Y.
        • Mahmoud A.N.
        • Kumbhani D.J.
        • Bhatt D.L.
        • Bavry A.A.
        Complete or culprit-only revascularization for patients with multivessel coronary artery disease undergoing percutaneous coronary intervention: a pairwise and network meta-analysis of randomized trials.
        JACC Cardiovasc Interv. 2017; 10: 315-324
        • Ibanez B.
        • James S.
        • Agewall S.
        • et al.
        2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC).
        Eur Heart J. 2018; 39: 119-177
        • Thiele H.
        • Akin I.
        • Sandri M.
        • et al.
        PCI strategies in patients with acute myocardial infarction and cardiogenic shock.
        N Engl J Med. 2017; 377: 2419-2432
        • Thiele H.
        • Akin I.
        • Sandri M.
        • et al.
        One-year outcomes after PCI strategies in cardiogenic shock.
        N Engl J Med. 2018; 379: 1699-1710
        • Tarantini G.
        • D’Amico G.
        • Brener S.J.
        • et al.
        Survival after varying revascularization strategies in patients with ST-segment elevation myocardial infarction and multivessel coronary artery disease: a pairwise and network meta-analysis.
        JACC Cardiovasc Interv. 2016; 9: 1765-1776
        • Guo W.Q.
        • Li L.
        • Su Q.
        • et al.
        Optimal timing of complete revascularization in patients with ST-segment elevation myocardial infarction and multivessel disease: a pairwise and network meta-analysis.
        Clin Epidemiol. 2018; 10: 1037-1051
        • Shishehbor M.H.
        • Lauer M.S.
        • Singh I.M.
        • et al.
        In unstable angina or non-ST-segment acute coronary syndrome, should patients with multivessel coronary artery disease undergo multivessel or culprit-only stenting?.
        J Am Coll Cardiol. 2007; 49: 849-854
        • Rathod K.S.
        • Koganti S.
        • Jain A.K.
        • et al.
        Complete versus culprit-only lesion intervention in patients with acute coronary syndromes.
        J Am Coll Cardiol. 2018; 72: 1989-1999
        • Amsterdam E.A.
        • Wenger N.K.
        • Brindis R.G.
        • et al.
        2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
        J Am Coll Cardiol. 2014; 64: e139-e228
        • Sardella G.
        • Lucisano L.
        • Garbo R.
        • et al.
        Single-staged compared with multi-staged PCI in multivessel NSTEMI patients: the SMILE trial.
        J Am Coll Cardiol. 2016; 67: 264-272
        • Gasior M.
        • Zembala M.O.
        • Tajstra M.
        • et al.
        Hybrid revascularization for multivessel coronary artery disease.
        JACC Cardiovasc Interv. 2014; 7: 1277-1283
        • Tajstra M.
        • Hrapkowicz T.
        • Hawranek M.
        • et al.
        Hybrid coronary revascularization in selected patients with multivessel disease: 5-year clinical outcomes of the prospective randomized pilot study.
        JACC Cardiovasc Interv. 2018; 11: 847-852
        • Sardar P.
        • Kundu A.
        • Bischoff M.
        • et al.
        Hybrid coronary revascularization versus coronary artery bypass grafting in patients with multivessel coronary artery disease: a meta-analysis.
        Catheter Cardiovasc Interv. 2018; 91: 203-212
        • Puskas J.D.
        • Halkos M.E.
        • DeRose J.J.
        • et al.
        Hybrid coronary revascularization for the treatment of multivessel coronary artery disease: a multicenter observational study.
        J Am Coll Cardiol. 2016; 68: 356-365
        • Farooq V.
        • Serruys P.W.
        • Zhang Y.
        • et al.
        Short-term and long-term clinical impact of stent thrombosis and graft occlusion in the SYNTAX trial at 5 years: Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery trial.
        J Am Coll Cardiol. 2013; 62: 2360-2369
        • Gaudino M.
        • Benedetto U.
        • Fremes S.
        • et al.
        Radial-artery or saphenous-vein grafts in coronary-artery bypass surgery.
        N Engl J Med. 2018; 378: 2069-2077
        • Panoulas V.F.
        • Colombo A.
        • Margonato A.
        • Maisano F.
        Hybrid coronary revascularization: promising, but yet to take off.
        J Am Coll Cardiol. 2015; 65: 85-97
        • Serruys P.W.
        • Unger F.
        • Sousa J.E.
        • et al.
        Comparison of coronary-artery bypass surgery and stenting for the treatment of multivessel disease.
        N Engl J Med. 2001; 344: 1117-1124
        • van den Brand M.J.
        • Rensing B.J.
        • Morel M.A.
        • et al.
        The effect of completeness of revascularization on event-free survival at one year in the ARTS trial.
        J Am Coll Cardiol. 2002; 39: 559-564
        • So S.I.
        Coronary artery bypass surgery versus percutaneous coronary intervention with stent implantation in patients with multivessel coronary artery disease (the Stent or Surgery trial): a randomised controlled trial.
        Lancet. 2002; 360: 965-970
        • Hueb W.
        • Soares P.R.
        • Gersh B.J.
        • et al.
        The medicine, angioplasty, or surgery study (MASS-II): a randomized, controlled clinical trial of three therapeutic strategies for multivessel coronary artery disease: one-year results.
        J Am Coll Cardiol. 2004; 43: 1743-1751
        • Head S.J.
        • Davierwala P.M.
        • Serruys P.W.
        • et al.
        Coronary artery bypass grafting vs percutaneous coronary intervention for patients with three-vessel disease: final five-year follow-up of the SYNTAX trial.
        Eur Heart J. 2014; 35: 2821-2830
        • Kamalesh M.
        • Sharp T.G.
        • Tang X.C.
        • et al.
        Percutaneous coronary intervention versus coronary bypass surgery in United States veterans with diabetes.
        J Am Coll Cardiol. 2013; 61: 808-816
        • Di Mario C.
        • Mara S.
        • Flavio A.
        • et al.
        Single vs multivessel treatment during primary angioplasty: results of the multicentre randomised HEpacoat for cuLPrit or multivessel stenting for Acute Myocardial Infarction (HELP AMI) study.
        Int J Cardiovasc Intervent. 2004; 6: 128-133
        • Politi L.
        • Sgura F.
        • Rossi R.
        • et al.
        A randomised trial of target-vessel versus multi-vessel revascularisation in ST-elevation myocardial infarction: major adverse cardiac events during long-term follow-up.
        Heart. 2010; 96: 662-667
        • Ghani A.
        • Dambrink J.H.
        • van ‘t Hof A.W.
        • Ottervanger J.P.
        • Gosselink A.T.
        • Hoorntje J.C.
        Treatment of non-culprit lesions detected during primary PCI: long-term follow-up of a randomised clinical trial.
        Neth Heart J. 2012; 20: 347-353
        • Zhang J.
        • Wang Q.
        • Yang H.
        • et al.
        Evaluation of different revascularization strategies for patients with acute myocardial infarction with lesions of multiple coronary arteries after primary percutaneous coronary intervention and its economic evaluation.
        Zhonghua Wei Zhong Bing Ji Jiu Yi Xue. 2015; 27 ([in Chinese]): 169-174
        • Hamza M.
        • Mahmoud N.
        • Elgendy I.Y.
        A randomized trial of complete versus culprit-only revascularization during primary percutaneous coronary intervention in diabetic patients with acute ST elevation myocardial infarction and multi vessel disease.
        J Interv Cardiol. 2016; 29: 241-247