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Thorac Cardiovasc Surg
DOI: 10.1055/s-0044-1787014
Original Cardiovascular

Coronary Artery Bypass Grafting versus Percutaneous Coronary Intervention in Patients with Chronic Total Occlusion

Hristo Kirov   *
1   Department of Cardiothoracic Surgery, Jena University Hospital, Jena, Germany
,
Johannes Fischer   *
1   Department of Cardiothoracic Surgery, Jena University Hospital, Jena, Germany
,
Tulio Caldonazo   *
1   Department of Cardiothoracic Surgery, Jena University Hospital, Jena, Germany
,
Panagiotis Tasoudis
2   Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, United States
,
Angelique Runkel
1   Department of Cardiothoracic Surgery, Jena University Hospital, Jena, Germany
,
Giovanni Jr. Soletti
3   Weill Cornell Medicine, New York, New York, United States
,
Gianmarco Cancelli
3   Weill Cornell Medicine, New York, New York, United States
,
Michele Dell'Aquila
3   Weill Cornell Medicine, New York, New York, United States
,
Murat Mukharyamov
1   Department of Cardiothoracic Surgery, Jena University Hospital, Jena, Germany
,
Torsten Doenst
1   Department of Cardiothoracic Surgery, Jena University Hospital, Jena, Germany
› Author Affiliations Funding TC was funded by the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation) Clinician Scientist Program OrganAge funding number 413668513, by the Deutsche Herzstiftung (DHS, German Heart Foundation) funding number S/03/23, and by the Interdisciplinary Center of Clinical Research of the Medical Faculty Jena.
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Abstract

Objectives Mechanisms of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) differ as CABG provides surgical collateralization and may prolong life by preventing future myocardial infarctions (MIs). However, evidence for CABG in patients with chronic total occlusion (CTO) has not been fully elucidated and the impact of PCI is discussed controversially.

Methods We performed a meta-analysis of studies comparing outcomes in patients with/without multivessel disease undergoing CABG or PCI for CTO. The primary outcome was long-term all-cause mortality (≥5 years). Secondary outcomes were MIs, repeat revascularization, cardiac mortality, major adverse cardiovascular events, and stroke, as well as short-term mortality (30 days/in-hospital) and stroke. A pooled Kaplan–Meier survival curve after reconstruction analysis was generated. Random-effects models were used.

Results Six studies totaling 12,504 patients were included. In the pooled Kaplan–Meier analysis, PCI showed a significantly higher risk of death in the follow-up compared with CABG (hazard ratio [HR]: 2.12, 95% confidence interval [CI]: 1.88–2.38, p < 0.01). During the observation period, PCI was also associated with higher rates of MI (odds ratio [OR]: 2.86, 95% CI: 1.82–4.48, p < 0.01) and more repeat revascularization (OR: 4.88, 95% CI: 1.99–11.91, p = 0.0005). The other outcomes did not show significant differences.

Conclusion CABG is associated with superior survival to PCI over time in patients with CTO who are eligible for both PCI and CABG. This survival advantage is associated with fewer events of MI and repeat revascularization.

Keywords

coronary artery bypass grafting - percutaneous coronary intervention - coronary artery disease - chronic total occlusion

Note

This study was accepted for presentation at the DGTHG annual meeting 2024 in Hamburg, Germany. Its abstract was ranked among the top 25 submissions.


Data Availability Statement

The data underlying this article are available in the article and in its online supplementary material.


Authors' Contribution

H.K., J.F., and T.C. designed the study, as well as coordinated and performed the major steps of the work regarding literature review, study selection, data management, and manuscript writing. Due to the fact that a meta-analysis of reconstructed time-to-event data is significantly effort demanding, the authors will share the first authorship. P.T. helped extensively with the statistical approach (especially with the Cox regression model and the proportional hazards assumption tests). A.R., G.S., and G.C. qualified the studies according to the risk of bias, checked the data abstraction, built the tables, and organized the results. M.D. and M.M. analyzed the preliminary data and were involved in the international project registration. T.D. was directly involved with the project supervision, manuscript review, and editing and was also consulted for study accuracy verification together with H.K. in cases of conflict. All the authors read and approved the final version of the manuscript.


* These authors contributed equally.


Supplementary Material



Publication History

Received: 28 December 2023

Accepted: 29 April 2024

Article published online:
17 May 2024

© 2024. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Doenst T, Haverich A, Serruys P. et al. PCI and CABG for treating stable coronary artery disease: JACC review topic of the week. J Am Coll Cardiol 2019; 73 (08) 964-976
    CrossrefPubMedGoogle Scholar
  • 2 Jeroudi OM, Alomar ME, Michael TT. et al. Prevalence and management of coronary chronic total occlusions in a tertiary Veterans Affairs hospital. Catheter Cardiovasc Interv 2014; 84 (04) 637-643
    CrossrefPubMedGoogle Scholar
  • 3 Roth GA, Mensah GA, Johnson CO. et al; GBD-NHLBI-JACC Global Burden of Cardiovascular Diseases Writing Group. Global burden of cardiovascular diseases and risk factors, 1990–2019: update from the GBD 2019 study. J Am Coll Cardiol 2020; 76 (25) 2982-3021
    CrossrefPubMedGoogle Scholar
  • 4 Zimarino M, Ausiello A, Contegiacomo G. et al. Rapid decline of collateral circulation increases susceptibility to myocardial ischemia: the trade-off of successful percutaneous recanalization of chronic total occlusions. J Am Coll Cardiol 2006; 48 (01) 59-65
    CrossrefPubMedGoogle Scholar
  • 5 Ibrahem A, Farag M, Gue YX, Spinthakis N, Al-Atta A, Egred M. Meta-analysis comparing long-term clinical outcomes of percutaneous coronary intervention versus no intervention in patients with chronic total occlusion. Heart Views 2023; 24 (02) 104-108
    CrossrefPubMedGoogle Scholar
  • 6 Glineur D, Hanet C. Competitive flow in coronary bypass surgery: is it a problem?. Curr Opin Cardiol 2012; 27 (06) 620-628
    CrossrefPubMedGoogle Scholar
  • 7 Doenst T, Bonow RO, Bhatt DL, Falk V, Gaudino M. Improving terminology to describe coronary artery procedures: JACC review topic of the week. J Am Coll Cardiol 2021; 78 (02) 180-188
    CrossrefPubMedGoogle Scholar
  • 8 Kucukseymen S, Iannaccone M, Grantham JA. et al. Association of successful percutaneous revascularization of chronic total occlusions with quality of life: a systematic review and meta-analysis. JAMA Netw Open 2023; 6 (07) e2324522 –e22
    CrossrefPubMedGoogle Scholar
  • 9 Obedinskiy AA, Kretov EI, Boukhris M. et al. The IMPACTOR-CTO Trial. JACC Cardiovasc Interv 2018; 11 (13) 1309-1311
    CrossrefPubMedGoogle Scholar
  • 10 Brilakis ES, Mashayekhi K, Tsuchikane E. et al. Guiding principles for chronic total occlusion percutaneous coronary intervention. Circulation 2019; 140 (05) 420-433
    CrossrefPubMedGoogle Scholar
  • 11 Mitomo S, Demir OM, Colombo A, Nakamura S, Chieffo A. What the surgeon needs to know about percutaneous coronary intervention treatment of chronic total occlusions. Ann Cardiothorac Surg 2018; 7 (04) 533-545
    CrossrefPubMedGoogle Scholar
  • 12 Farooq V, Serruys PW, Garcia-Garcia HM. et al. The negative impact of incomplete angiographic revascularization on clinical outcomes and its association with total occlusions: the SYNTAX (Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery) trial. J Am Coll Cardiol 2013; 61 (03) 282-294
    CrossrefPubMedGoogle Scholar
  • 13 Zein R, Seth M, Othman H. et al. Association of operator and hospital experience with procedural success rates and outcomes in patients undergoing percutaneous coronary interventions for chronic total occlusions: insights from the blue cross blue shield of michigan cardiovascular consortium. Circ Cardiovasc Interv 2020; 13 (08) e008863
    CrossrefPubMedGoogle Scholar
  • 14 Watkins AC, Ghoreishi M, Maassel NL. et al. Programmatic and surgeon specialization improves mortality in isolated coronary bypass grafting. Ann Thorac Surg 2018; 106 (04) 1150-1158
    CrossrefPubMedGoogle Scholar
  • 15 Wang C, Liu S, Kamronbek R. et al. Percutaneous coronary intervention versus coronary artery bypass grafting for chronic total occlusion of coronary arteries: a systematic review and meta-analysis. J Interv Cardiol 2023; 2023: 9928347
    CrossrefPubMedGoogle Scholar
  • 16 Zheng YY, Gao Y, Chen Y. et al. Outcomes of chronic total occlusions in coronary arteries according to three therapeutic strategies: a meta-analysis with 6985 patients from 8 published observational studies. Rev Bras Cir Cardiovasc 2019; 34 (06) 645-652
    CrossrefPubMedGoogle Scholar
  • 17 Neumann F-J, Sousa-Uva M, Ahlsson A. et al; ESC Scientific Document Group. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J 2019; 40 (02) 87-165
    CrossrefPubMedGoogle Scholar
  • 18 Head SJ, Milojevic M, Daemen J. et al. Mortality after coronary artery bypass grafting versus percutaneous coronary intervention with stenting for coronary artery disease: a pooled analysis of individual patient data. Lancet 2018; 391 (10124): 939-948
    CrossrefPubMedGoogle Scholar
  • 19 Caldonazo T, Kirov H, Riedel LL, Gaudino M, Doenst T. Comparing CABG and PCI across the globe based on current regional registry evidence. Sci Rep 2022; 12 (01) 22164
    CrossrefPubMedGoogle Scholar
  • 20 Gaudino M, Hameed I, Farkouh ME. et al. Overall and cause-specific mortality in randomized clinical trials comparing percutaneous interventions with coronary bypass surgery: a meta-analysis. JAMA Intern Med 2020; 180 (12) 1638-1646
    CrossrefPubMedGoogle Scholar
  • 21 Lin S, Guan C, Wu F. et al. Coronary artery bypass grafting and percutaneous coronary intervention in patients with chronic total occlusion and multivessel disease. Circ Cardiovasc Interv 2022; 15 (02) e011312
    CrossrefPubMedGoogle Scholar
  • 22 Álvarez-Contreras L, Flores-Umanzor E, Cepas-Guillen P. et al. Clinical impact of medical therapy versus revascularization in patients with chronic coronary total occlusions. J Invasive Cardiol 2021; 33 (01) E2-E8
    PubMedGoogle Scholar
  • 23 Trzeciak P, Desperak P, Duda-Pyszny D. et al. Long-term outcomes of 11 021 patients with chronic coronary syndromes and after coronary angiography: the PRESAGE registry. Pol Arch Intern Med 2020; 130 (12) 1043-1052
    PubMedGoogle Scholar
  • 24 Lee SE, Lee HY, Cho HJ. et al. Coronary artery bypass graft versus percutaneous coronary intervention in acute heart failure. Heart 2020; 106 (01) 50-57
    CrossrefPubMedGoogle Scholar
  • 25 Tomasello SD, Boukhris M, Giubilato S. et al. Management strategies in patients affected by chronic total occlusions: results from the Italian Registry of Chronic Total Occlusions. Eur Heart J 2015; 36 (45) 3189-3198
    CrossrefPubMedGoogle Scholar
  • 26 Kim BS, Yang JH, Jang WJ. et al. Clinical outcomes of multiple chronic total occlusions in coronary arteries according to three therapeutic strategies: bypass surgery, percutaneous intervention and medication. Int J Cardiol 2015; 197: 2-7
    CrossrefPubMedGoogle Scholar