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10-Year Mortality After PCI or CABG for Coronary Total Occlusion
Quick Takes
- In patients with coronary total occlusion (TO), there were no significant differences in 10-year all-cause mortality between patients with recanalized (PCI) or revascularized (CABG) TO, whether treatment for TO was successful or not.
- When patients with TO were stratified according to presence of three-vessel disease or left main disease, there was still no difference in 10-year all-cause mortality between PCI and CABG.
Study Questions:
What is the impact on 10-year all-cause mortality of percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) for treatment of coronary total occlusion (TO) in patients with complex coronary artery disease (CAD)?
Methods:
This is a subanalysis of the SYNTAXES (Synergy Between PCI With Taxus and Cardiac Surgery Extended Survival) study, which was an extended 10-year follow-up beyond the 5-year follow-up of the SYNTAX study, a prospective, randomized, controlled study of patients with three-vessel disease (3VD) or left main disease (LM) who were randomized 1:1 to either PCI or CABG.
While in the SYNTAX study TO ≤3 months and >3 months were specified, both were considered as TO for this study, and TO was defined as absolutely no flow through the lesion (Thrombolysis In Myocardial Infarction [TIMI] flow grade 0). The total number of randomized patients were stratified by presence or absence of TO, and those with TO were stratified according to the result after recanalization or revascularization and by the presence of 3VD or LM.
The primary endpoint of this study was all-cause mortality at 10 years. Analyses were performed as intention-to-treat. Kaplan-Meier and Cox proportional regression were performed to assess difference in mortality. Potential confounders included in the Cox regression model were: age, sex, body mass index, medically treated diabetes, hypertension, dyslipidemia, current smoker, previous myocardial infarction, previous cerebrovascular disease, peripheral vascular disease, chronic obstructive pulmonary disease, chronic kidney disease, left ventricular ejection fraction, clinical presentation, disease type (3VD or LM), and anatomical SYNTAX score.
Results:
Of 1,800 randomized patients in the SYNTAX study, 460 patients (25.6%, 543 lesions) had ≥1 TO. Of these 460 patients, there were 223 in the CABG group and 237 in the PCI group. Baseline characteristics in both groups were similar except for higher prevalence of hypertension in the PCI group. All TO’s were successfully recanalized in 43.5% of patients after PCI and successfully revascularized in 60.5% of patients with CABG (p < 0.001).
There was no significant difference in 10-year all-cause mortality when comparing patients with TO successfully recanalized with PCI versus those that were not (29.9% vs. 29.4%; unadjusted hazard ratio [HR], 1.041; 95% confidence interval [CI], 0.645-1.681; p = 0.868), nor was there a difference when comparing patients with TO successfully revascularized with CABG versus those that were not (28.0% vs. 21.4%; HR, 1.311; 95% CI, 0.746-2.303; p = 0.346). The lack of significant difference in mortality was the same in multivariate analysis (PCI arm: adjusted HR, 0.992; 95% CI, 0.474-2.075; p = 0.982; CABG arm: adjusted HR, 0.656; 95% CI, 0.281-1.533; p = 0.330).
When stratifying patients by disease (3VD vs. LM), again there was no significant difference in 10-year all-cause mortality between PCI and CABG (LM group: PCI 30.5% vs. CABG 40.9%; HR, 1.539; 95% CI, 0.814-2.911; p = 0.185; 3VD group: PCI 29.3% vs. CABG 21.0%; HR, 0.673; 95% CI, 0.437-1.037; p = 0.073).
Conclusions:
There was no difference in 10-year all-cause mortality in patients with coronary TO in the setting of complex CAD, regardless of whether they were treated with PCI or CABG, whether TO treatment was successful or not, or whether they had 3VD or LM.
Perspective:
Patients with total coronary occlusion can be a challenge to manage both surgically and percutaneously. From a surgical standpoint, on preoperative angiogram, it can be difficult to gauge the true size of the target vessel, depending on the direction of collateral flow and the size of the collateral network. If the target vessel is small or there is poor outflow, the bypass graft is more likely to occlude over time. From a percutaneous standpoint, successful management of CTO can depend on, among other factors, the particular native and collateral anatomy allowing antegrade and retrograde access to the TO, length of TO, quality of the vessel, and age of TO.
This study shows that treatment of TO in the setting of complex CAD, whether surgical or percutaneous, or performed or not, showed no difference between groups with regard to all-cause mortality at 10 years. In their discussion, the authors include as possible explanations incomplete characterization of more complex TO lesions with lack of contemporary devices or techniques to treat them, as well as inadequate assessment of myocardial viability in the affected area prior to treatment. They did note despite no difference in mortality, assessment of angina status with the Seattle Angina Questionnaire showed that both PCI and CABG improved the ratios of patients who were angina-free at all follow-up time points (see Supplemental Materials).
Revascularization, recanalization, and no treatment of TO are all on the table for patients with complex CAD with this challenging anatomy. Heart Team evaluation can be invaluable in assessing these patients and strategizing an appropriate approach.
Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Prevention, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and SIHD, Interventions and ACS, Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Nuclear Imaging, Hypertension
Keywords: Acute Coronary Syndrome, Angina Pectoris, Angiography, Cardiac Surgical Procedures, Coronary Artery Bypass, Coronary Artery Disease, Coronary Occlusion, Hypertension, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Percutaneous Coronary Intervention, Thrombolytic Therapy
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