Repeat revascularization occurs more often following percutaneous coronary intervention (PCI) than coronary artery bypass grafting (CABG). The need for repeat revascularization is a less important clinical endpoint than death, stroke or myocardial infarction. However, it can have an impact on quality of life, risk of hospitalization and mortality.
In the present study of Giustino et al., a sub-study of the EXCEL trial, the investigators evaluated the incidence, timing and impact on mortality of the need for repeat coronary revascularization after PCI or CABG for left main coronary artery disease (CAD).
The EXCEL trial performed between the years 2010 and 2014 randomized 1905 subjects to be managed by either PCI (n=948) or CABG (n=957). Subjects were followed up for a period of 3 years. The present study is a secondary analysis from the EXCEL trial. Giustino et. al. examined the incidence, risk factors and prognostic impacts of repeat revascularization on mortality by using time-varying Cox regression models. They also compared outcomes between patients undergoing PCI vs CABG.
346 repeat revascularization procedures were performed in 185 patients from the EXCEL trial. The median time from index intervention to the first repeat revascularization was 347 days post PCI, and 257 days post CABG. Most of the differences in repeat revascularization rates between the 2 interventions only became apparent more than 6 months after the index intervention.
Repeat revascularization more common after PCI
PCI was associated with higher rates of repeat revascularization (12.9% vs. 7.6%; hazard ratio: 1.73; 95% confidence interval: 1.28 to 2.33; p = 0.0003).
Following PCI, repeat revascularization was usually necessitated by stent-related complications or the development of new obstructive coronary lesions far from the stented vascular segment. Following CABG, repeat vascularization was usually necessitated by the progression of vessel disease distal to the site of anastomosis, or by arterial or venous graft occlusion.
Additional factors associated with an increased risk for repeat revascularization after PCI included higher body mass index, insulin-treated diabetes, and hemodynamic support during the procedure. Additional factors associated with an increased risk for repeat revascularization following CABG included younger age, female sex, and peripheral vascular disease.
Repeat revascularization associated with increased risk of mortality
The need for repeat revascularization was independently associated with an increased risk for 3-year all-cause mortality (adjusted hazard ratio: 2.05; 95% confidence interval: 1.13 to 3.70; p ¼ 0.02) and cardiovascular mortality (adjusted hazard ratio: 4.22; 95% confidence interval: 2.10 to 8.48; p < 0.0001), consistently after both PCI and CABG.
Mortality was greater after repeat revascularization by CABG but not PCI, reflecting the different risk profiles of these interventions. This observation suggests that CABG should be reserved for repeat revascularization procedures not amenable to repeat PCI-regardless of which method was utilized for the index procedure. Although target vessel revascularization (TVR) and target lesion revascularization (TLR) were both associated with an increased risk of mortality, target vessel non–target lesion revascularization and non–target vessel revascularization were not. Giustino et. al. noted a significant increased risk for all-cause and cardiovascular mortality for both TVR and TLR consistently after both PCI and CABG.
Giustino et. al. suggest that measures to reduce repeat revascularization, including improved drug-eluting stents and aggressive risk factor control, may improve prognosis after both PCI and CABG.
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Author: Kelly Schoonderwoerd
Originial article: Giustino et al. JACC Cardiovasc Interv. 2020 Feb 10;13(3):375-387.
