Restenosis, Target Vessel Revascularization, and Mortality

Study Questions:

Does uncomplicated target vessel revascularization (TVR) after percutaneous coronary intervention (PCI) have an impact on long-term survival?

Methods:

The authors pooled patient data from 21 randomized trials to assess the impact of TVR on long-term all-cause mortality. Patients dying the same day as or the day after the target lesion revascularization (TLR) procedure as well as those with myocardial infarction (MI) the day before, the same day as, or the day after TLR were excluded.

Results:

Of the 32,524 patients in the study, with a median follow-up of 37 months, 2,330 (7.2%) patients underwent a nonemergent, uncomplicated TLR procedure and 810 patients (2.5%) underwent a nonemergent, uncomplicated non-TLR TVR procedure. There were 1,739 deaths in patients without TVR (incidence rate 1.87 per 100 patient-years), 144 deaths in patients with nonemergent, uncomplicated TLR (incidence rate 2.45 per 100 patient-years), and 49 deaths in patients with non-TLR TVR (incidence rate 2.67 per 100 patient-years). TLR was an independent predictor of mortality (adjusted hazard ratio, 1.23; 95% confidence interval, 1.04-1.45; p = 0.02). Patients undergoing TLR had significantly higher rates of nonprocedure-related MI and MI occurring after TLR was an independent predictor of mortality (hazard ratio, 3.82; 95% confidence interval, 2.44-5.99; p < 0.0001).

Conclusions:

Nonemergent, uncomplicated TLR after PCI is an independent predictor of long-term mortality.

Perspective:

The incidence of restenosis and the consequent need for TLR in patients undergoing PCI has come down with the current second-generation drug-eluting stents. Restenosis, however, is not a completely benign event, and as this study suggests, may be associated with worse long-term survival. This study invokes the need for meticulous technique and better devices to reduce restenosis and TLR and thereby potentially improve long-term survival.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Stable Ischemic Heart Disease, Aortic Surgery, Cardiac Surgery and SIHD, Chronic Angina

Keywords: Coronary Restenosis, Drug-Eluting Stents, Incidence, Mortality, Myocardial Infarction, Myocardial Revascularization, Percutaneous Coronary Intervention


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