Repeat Revascularization After PCI and CABG

Study Questions:

What are the incidences, predictors, characteristics, and outcomes of repeat revascularization during 5-year follow-up of the SYNTAX (Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery) trial?

Methods:

Incidence and timing of repeat revascularization and its relation to the long-term composite safety endpoint of death, stroke, and myocardial infarction (MI) were analyzed in the SYNTAX trial (n = 1,800) using Kaplan-Meier analysis.

Results:

At 5 years, repeat revascularization occurred more often after initial percutaneous coronary intervention (PCI) than after initial coronary artery bypass grafting (CABG) (25.9 vs. 13.7%, respectively; p < 0.001), and more often consisted of multiple repeat revascularizations (9.0 vs. 2.8%, respectively; p = 0.022). Significantly more repeat PCI procedures were performed on de novo lesions in patients after initial PCI than initial CABG (33.3 vs. 13.4%, respectively, p < 0.001). At 5-year follow-up, patients who underwent repeat revascularization versus patients not undergoing repeat revascularization had significantly higher rates of the composite safety endpoint of death, stroke, and MI after initial PCI (33.8 vs. 16.6%, respectively; p < 0.001), and a trend was found after initial CABG (22.4 vs. 15.8%, respectively; p = 0.07). After multivariate adjustment, repeat revascularization was an independent predictor of the composite safety endpoint after both initial PCI (hazard ratio [HR], 2.2; 95% confidence interval [CI], 1.6-3.0; p < 0.001) and initial CABG (HR, 1.8; 95% CI, 1.2-2.9; p = 0.011).

Conclusions:

The authors concluded that repeat revascularization rates are significantly higher after initial PCI than after initial CABG for complex coronary disease.

Perspective:

This study reports that repeat revascularization rates were significantly higher after PCI compared with CABG at early, intermediate, and long-term intervals, during 5-year follow-up of the SYNTAX trial. Furthermore, long-term results showed higher rates of clinically meaningful endpoints after repeat revascularization in the PCI group, which drove the differences favoring CABG over PCI in the more complex patients in the SYNTAX trial overall. Comparison of long-term results of patients who did not undergo repeat revascularization revealed similar outcomes between PCI and CABG, suggesting that careful patient selection is indicated in choosing a revascularization strategy using a multidisciplinary heart team.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Aortic Surgery, Interventions and Coronary Artery Disease

Keywords: Cardiac Surgical Procedures, Coronary Artery Bypass, Coronary Artery Disease, Myocardial Infarction, Myocardial Revascularization, Percutaneous Coronary Intervention, Stroke, Treatment Outcome


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