CABG bests PCI in most patients with chronic total occlusion, multivessel disease
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In a retrospective study of patients with chronic total occlusion and multivessel CAD, CABG conferred better long-term outcomes than PCI, according to data presented at the virtual PCR e-Course.
“No randomized controlled trials or large registries have been designed to compare long-term prognosis of PCI or CABG in patients with CTO and multivessel disease,” Bo Xu, MBBS, director of the catheterization laboratories at Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, said during a presentation. “Thus, the present study aimed to evaluate 5-year outcomes of PCI vs. CABG in a large cohort of patients with CTO and multivessel disease.”
Xu and colleagues analyzed 4,324 patients with CTO and multivessel disease who underwent PCI (mean age, 58 years; 84% men) or CABG (mean age, 60 years; 83% men) at Fu Wai Hospital between 2010 and 2013. The primary outcome was death, MI or stroke at 5 years.
At 5 years, after adjustment via inverse probability of treatment weighting, the primary outcome favored the CABG group (adjusted HR = 1.21; 95% CI, 1.02-1.44), as did all-cause mortality (aHR = 1.32; 95% CI, 1.04-1.67), cardiac mortality (aHR = 1.81; 95% CI, 1.31-2.49), MI (aHR = 7; 95% CI, 4.58-10.68), repeat revascularization (aHR = 7.93; 95% CI, 6.01-10.46) and target vessel revascularization (aHR = 6.36; 95% CI, 4.58-8.82), Xu said.
The 5-year risk for stroke was lower in the PCI group (aHR = 0.37; 95% CI, 0.25-0.54) and there was no difference between the groups in stent thrombosis or symptomatic graft occlusion, he said.
However, he said, in subgroup analysis based on residual SYNTAX score, among those recommended for PCI or either PCI or CABG, there was no difference in the primary outcome between those who received PCI and those who received CABG (aHR = 0.94; 95% CI, 0.75-1.17), but among those recommended for CABG, those who received PCI had elevated risk for the primary outcome compared with those who received CABG (aHR = 1.55; 95% CI, 1.14-2.09).
In addition, in a sensitivity analysis, those who received PCI and had a residual SYNTAX score of 8 or less did not have greater risk for the primary outcome than those who received CABG, but those who received PCI and had a residual SYNTAX score of more than 8 did, Xu said.
“CABG may still be the gold standard for patients with CTO and multivessel disease; however, state-of-the-art PCI with appropriate indication could be considered an appropriate alternative in the clinical setting,” he said.
“This kind of data will help us guide our clinical decisions,” William Wijns, MD, Science Foundation Ireland Professor of Interventional Cardiology at the Lambe Institute for Translational Medicine, Curam and Saolta University Healthcare Group, National University of Ireland, Galway, said in a commentary after the presentation. “There is advantage for CABG in those patients with extensive disease, but if you split the indication for PCI as certain/appropriate or not so certain/inappropriate, then you start to see there is equipoise when the PCI indication according to the models they have applied is adequate or certain.”
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Xu B, et al. PCR e-Course 2020 Late-Breaking Trials - part 2. Presented at: PCR e-Course; June 25-27, 2020 (virtual meeting).
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