Reply
David M. Safley, MD, FACC*,
Steven P. Marso, MD, FACC,
John A. House, MS,
J. Aaron Grantham, MD, FACC,
Barry D. Rutherford, MD, FACC
Drs. Shishehbor and Whitlow raise an excellent point regarding our analysis of predictors of procedural success in chronic total occlusion (CTO) angioplasty (1). There are several aspects regarding the use of glycoprotein (GP) IIb/IIIa antagonist use in CTO percutaneous coronary intervention (PCI) that need to be recognized to put the results of our analysis in context. First, GP IIb/IIIa antagonists were used in the later years of our analysis. Second, GP IIb/IIIa antagonists were administered after successful crossing of the target lesion in CTO PCI in the vast majority of cases. Third, GP IIb/IIIa is not a patient pre-procedural variable and thus is subject to important selection bias. We think including GP IIb/IIIa antagonist use in our model is justified to evaluate the possibility of both benefit and harm. In our analysis there did not seem to be any signal for harm. However, their use in the manner described above does bias this analysis. We have described technical success (crossing the lesion and performing angioplasty with or without stenting and <40% residual stenosis) as well as procedural success (technical success without major adverse clinical events while in the hospital). Therefore, using GP IIb/IIIa antagonists only in patients who have already had a successful crossing of their CTO lesion does increase the likelihood that they will have procedural success by the virtue of being well on the way to technical success. We agree wholeheartedly that these agents should be administered only after the lesion has been crossed and intraluminal wire position has been confirmed.
We have repeated the analysis excluding GP IIb/IIIa antagonist use from the model, and the point estimates for the other variables are not significantly altered. In conclusion, we thank Drs. Shishehbor and Whitlow for raising this important point regarding the use of GP IIb/IIIa antagonists in CTO angioplasty and allowing us to expand on this important element of CTO PCI.
* University of Missouri–Kansas City, Saint Luke's Health System, Mid America Heart Institute, 4401 Wornall Road, Kansas City, Missouri 64111 (Email: dsafley{at}cc-pc.com).
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- Safley DM, House JA, Marso SP, Grantham JA, Rutherford BD. Improvement in survival following successful percutaneous coronary intervention of chronic total occlusion: variability by target vessel J Am Coll Cardiol Intv 2008;1:295-302.[Abstract/Free Full Text]
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Improved Survival After Percutaneous Coronary Intervention of Chronic Total Occlusion Varies by Target Vessel
- Mehdi H. Shishehbor and Patrick L. Whitlow
J. Am. Coll. Cardiol. Intv. 2008 1: 597-598.
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