Clinical Research & Data, Complete Revascularization

Italian Paper Evaluates Completeness of Revascularization in Complex CAD


Sergio Leonardi, MD, and Stefano De Servi, MD, discuss their paper evaluating the completeness of revascularization in patients with complex, stable coronary artery disease (CAD) who underwent PCI. In many of these patients, surgical revascularization was indicated under the 2018 European Society of Cardiology (ESC) guidelines.

Dr. De Servi states that this investigation aimed to assess adherence to the guideline recommendations concerning the modality of revascularization in patients with complex coronary artery disease. He summarizes the main recommendations from the ESC guidelines for myocardial revascularization in complex CAD, noting that the guidelines state that the modality of revascularization should be chosen according to SYNTAX score and clinical presentation of the patient and that complete revascularization should be prioritized. 

Dr. De Servi explains that the investigation analyzed medical records and coronary angiograms, and calculated SYNTAX scores for 336 patients—154 who did not have complex CAD and 182 who had complex CAD defined by ESC guidelines as at least one of the following: left anterior descending proximal disease, left main disease, three-vessel disease, SYNTAX score ≥23. Median LVEF in both patient groups was normal (50%) and STS scores were low (below 1), signifying that these patients were good candidates for surgery. Results showed that 17% of the patients with complex CAD had PCI despite guideline recommendation for coronary artery bypass graft (CABG) surgery in these patients.

Dr. Leonardi emphasizes that multidisciplinary decision making is a Class I recommendation in patients with complex CAD and that just one out of 10 patients in this analysis had a Heart Team consult. Dr. De Servi explains that the rate of ad-hoc PCI (PCI performed immediately after coronary angiography) was very high in both groups (84% in complex CAD group), and thus the Heart Team meetings were skipped.

Assessing the rate of incomplete revascularization using residual SYNTAX score (rSS) and SYNTAX revascularization index (SRI), the authors explained that they saw a very high rate of incomplete revascularization in the complex CAD patient group. Among patients who received PCI but ESC guidelines recommended CABG, the rate of incomplete revascularization 61.2% using the rSS and 77.4% using the SRI. “These percentages were significantly higher than those observed in patients who had a good recommendation for PCI,” Dr. De Servi notes, explaining that those rates for incomplete revascularization were 19.8% using rSS and 39% using SRI. 

Dr. Leonardi’s top take-home message from this data is, “Heart Team, while complex, it is important, especially in the stable patient.”

Looking at the rates of incomplete revascularization as a compelling call to action for interventionalists to do better with complete revascularization, Dr. De Servi concludes that interventional cardiologists should always strive to achieve the most complete revascularization possible, emphasizing, “If calcified vessels are found, rotablator must be used. If there are, it frequently happens in these patients, CTOs [chronic total occlusions], CTOs have to be addressed. If the center does not have the experience or the skill to treat CTOs, I think we must be humble and send the patient to a center with that capacity.”

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