Author + information
- Carlo Zivelonghi, MD,
- Maarten J. Suttorp, MD, PhD,
- Koen Teeuwen, MD,
- Jan Peter van Kuijk, MD, PhD,
- Jan A.S. van der Heyden, MD, PhD,
- Frank D. Eefting, MD,
- Benno J. Rensing, MD, PhD,
- Jurrien M. ten Berg, MD, PhD,
- Floris S. van den Brink, MD,
- Giovanni Benfari, MD,
- Jan G.P. Tijssen, PhD,
- Flavio Ribichini, MD,
- José P.S. Henriques, MD, PhD and
- Pierfrancesco Agostoni, MD, PhD∗ ()
- ↵∗Department of Cardiology, St. Antonius Ziekenhuis, Postbus 2500, 3430 EM Nieuwegein, the Netherlands
Chronic total occlusions (CTOs) represent the ultimate stage of coronary atherosclerosis, with commonly associated high plaque burden upstream and downstream of the occlusion itself. Physiological modifications in the vessel distal to the CTO lesion lead to negative vascular remodeling and plaque growth in this segment (1), which undergoes variable degrees of diameter improvement after successful recanalization (2). We report here the angiographic evolution and clinical impact of stenoses located in the segments distal to CTO lesions in a large cohort of patients, derived from 2 randomized clinical trials with mandatory angiographic follow-up at mid-term follow-up.
The present analysis is based on the PRISON (Primary Stenting of Occluded Native Coronary Arteries) III and IV trials (3,4). Briefly, after successful recanalization of coronary occlusions, patients were randomized to different second-generation drug-eluting stents. In both studies, angiographic and clinical follow-up was scheduled at 8 to 9 and 12 months, respectively. Of note, only CTO lesions (>3 months old) were herein analyzed.
Quantitative coronary analysis (QCA) was independently assessed offline according to standard indications (3,4). The target of QCA assessment was the distal segment, defined as that immediately downstream of the stented segment of the occlusion until the final bifurcation of the major epicardial vessel, and was analyzed at the end of the index procedure and on follow-up angiography, after intracoronary nitroglycerin was administered per protocol. Patients were divided into 3 groups: group A consisted of patients with presence of binary stenosis (≥50%) in the distal segment immediately after CTO recanalization who did not receive additional intervention during the index procedure, group B included patients with absence of binary stenosis in the distal segment, and group C included patients with binary stenoses in the distal segment, which underwent stenting during the index procedure, as by operator choice. In group C, QCA was performed before stenting. Angiographic endpoints were changes in QCA parameters in the distal segment at follow-up. Clinical endpoints consisted of death, myocardial infarction and target vessel revascularization at 12-month follow-up.
After exclusion of 279 patients (no angiographic follow-up, occlusions <3 months old, and angiograms inadequate for QCA), 355 patients were eligible for the analysis. Of these, 121 (34.1%) were included in group A, 173 (48.7%) in group B, and the remaining 61 (17.2%) in group C. Baseline demographic and angiographic characteristics were similar. Compared with group B, baseline QCA in group A disclosed significantly lower values of reference vessel diameter (2.09 ± 0.41 mm vs. 2.35 ± 0.45 mm), mean luminal diameter (1.64 ± 0.37 mm vs. 2.14 ± 0.43 mm), minimal luminal diameter (MLD) (0.82 ± 0.24 mm vs. 1.62 ± 0.41 mm), and diameter stenosis (61 ± 8% vs. 31 ± 9%, respectively) (p < 0.001 for all). When comparing group A with group C, lower reference vessel diameter (2.09 ± 0.41 mm vs. 2.35 ± 0.35 mm; p > 0.001) and mean luminal diameter (1.64 ± 0.37 mm vs. 1.78 ± 0.31 mm; p = 0.03) were observed in the first group, but with similar MLD (0.82 ± 0.24 mm vs. 0.88 ± 0.23 mm; p = 0.15) and diameter stenosis (61 ± 8% vs. 62 ± 7%; p = 0.18).
Angiographic assessment at follow-up showed improvements in luminal diameters in all groups, with greater increases in group A. In this group, compared with group B, MLD increased by 107 ± 75% versus 30 ± 31% (p < 0.001) and mean luminal diameter by 31 ± 22% versus 20 ± 18% (p > 0.001), despite persistently higher reference vessel diameter in group B (2.31 ± 0.43 mm vs. 2.66 ± 0.46 mm, p < 0.001). Furthermore, improvements in MLD and mean luminal diameter were similar to those in group C (107 ± 75% vs. 109 ± 94% and 31 ± 22% vs. 29 ± 26%, respectively, p = NS), in which, however, patients underwent stent implantation at the end of the index procedure. Most important, only 9 (7.4%) of the binary stenoses in group A persisted at follow-up, which was more frequent than in group B, in which 2 patients (1.2%, p = 0.01) showed disease progression, but similar to group C, in which 9 binary in-stent restenoses (14.8%, p = 0.18) were observed (Figure 1).
At clinical follow-up, groups A and B showed similar outcomes in terms of death (0 vs. 2 [1.2%], respectively), myocardial infarction (0 vs. 2 [1.2%], respectively), and target vessel revascularization (10 [8.3%] vs. 13 [7.5%]) (p = NS for all). No deaths or myocardial infarctions occurred in group C, but compared with group A, a mild trend toward a higher incidence of target vessel revascularization (11 [18%] vs. 10 [8.3%], respectively, p = 0.08) was observed, driven mainly by the incidence of in-stent restenosis.
According to our findings, patients presenting with significant stenosis in the segment distal to the CTO lesion after successful recanalization have angiographic and clinical outcomes comparable with those of patients without evidence of vessel narrowing in the same segment, also and especially if not treated with additional percutaneous coronary intervention and stent implantation. As a practical implication, a “watchful waiting” strategy should be considered when dealing with distal segment lesions after successful CTO recanalization.
Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- 2018 American College of Cardiology Foundation
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