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Incomplete Revascularization in the Era of Drug-Eluting Stents

Impact on Adverse Outcomes

Edward L. Hannan, PhD, FACC^_*,_*, Chuntao Wu, MD, PhD^_*,, Gary Walford, MD, FACC, David R. Holmes, MD, FACC, Robert H. Jones, MD, FACC^||, Samin Sharma, MD, FACC^¶, Spencer B. King, III, MD, MACC^#

^_* University at Albany, State University of New York, Albany, New York
Penn State Hershey College of Medicine, Hershey, Pennsylvania
St. Joseph's Hospital, Syracuse, New York
Mayo Clinic, Rochester, Minnesota
^|| Duke University Medical Center, Durham, North Carolina
^¶ Mt. Sinai Medical Center, New York, New York
^# St. Joseph's Hospital, Atlanta, Georgia

^_* Reprint requests and correspondence: Dr. Edward L. Hannan, Distinguished Professor and Associate Dean for Research, School of Public Health, State University of New York, University at Albany, One University Place, Rensselaer, New York 12144-3456 (Email: elh03{at}health.state.ny.us).

Objectives: We sought to compare outcomes for percutaneous coronary intervention patients undergoing complete revascularization (CR) and incomplete revascularization (IR) in the drug-eluting stent era.

Background: There have been relatively few studies that have examined the impact of IR in patients undergoing coronary stenting, particularly in the era of drug-eluting stents.

Methods: New York State's Percutaneous Coronary Intervention Reporting System was used to identify 11,294 stent patients with multivessel disease undergoing either IR or CR in 39 hospitals between October 1, 2003, and December 31, 2004. These patients were followed through December 31, 2005, and IR patients were subdivided based on the number of IR vessels and presence of a chronic total occlusion. Risk-adjusted mortality and mortality/myocardial infarction (MI) for CR and IR patients were compared at 18 months.

Results: Incomplete revascularization was performed in a total of 7,795 patients (69.0%). Incomplete revascularization was associated with higher 18-month mortality (adjusted hazard ratio [HR]: 1.23, 95% confidence interval [CI]: 1.04 to 1.45) and higher 18-month MI/mortality (adjusted HR: 1.27, 95% CI: 1.09 to 1.47). The risk-adjusted survival rates for CR and IR were 94.9% and 93.8% (p = 0.01). The risk-adjusted survival/freedom from MI rates were 93.3% and 91.7% (p = 0.002). Patients with 2 diseased vessels unattempted with a total occlusion were at highest risk (adjusted survival HR: 1.44, 95% CI: 1.14 to 1.82, risk-adjusted survival 94.9% vs. 92.9%, p = 0.002; and adjusted survival/freedom from MI: 1.50, 95% CI: 1.21 to 1.86, rates 93.3% vs. 90.3%, p < 0.001).

Conclusions: Patients undergoing coronary stenting who receive IR experience more adverse outcomes even in the era of drug-eluting stents. This has implications for choice of procedure and post-procedural monitoring.

Key Words: stent • incomplete revascularization • mortality

Abbreviations and Acronyms   CABG = coronary artery bypass graft   CR = complete revascularization   CTO = chronic total occlusion   DES = drug-eluting stent(s)   IR = incomplete revascularization   MI = myocardial infarction   PCI = percutaneous coronary interventions   PCIRS = Percutaneous Coronary Intervention Reporting System