Value of Complete Revascularization in a Single Setting

Dr. Rajan Patel Presents Supporting Data at TCT 2019

“I’m going to talk about some compelling data demonstrating the value of complete revascularization,” Dr. Rajan Patel states as he opens this TCT 2019 presentation, “and give you some provocative data suggesting that complete revascularization in a single setting may be better than staging complete revascularization.”

Dr. Patel then presents a case study to illustrate the benefits of complete revascularization, which he lists as:

  • Less early recurrent ischemia and subsequent procedures
  • Better tolerance of events in other coronary distributions
  • Preservation of LV function
  • Reduced rate of MI and sudden cardiac death

Dr. Patel follows with data showing that incomplete revascularization is common and that it has an impact on mortality. SYNTAX Trial data published by Farooq et al. in 2013 demonstrated a 9.1% rate of cardiac death in patients with incomplete revascularization compared with a 6% rate of cardiac death with complete revascularization (p=0.049). Data from the Mayo Clinic PCI Registry and other sources, including large meta-analyses, also reveal survival benefits and reductions in MACCE in patients receiving complete revascularization.

In addition, Dr. Patel presents data from Bangalore et al. published in 2015 that illustrates how PCI with complete revascularization is closing the gap with CABG. While MI was significantly more prevalent with PCI compared with CABG in patients with incomplete revascularization, there was no difference in MI rate among patients with complete revascularization in the CABG and PCI arms. “So, there seems to be a clear advantage of complete revascularization,” Dr. Patel states, “and if PCI is ever going to win against CABG, it looks like we have to start doing more complete revascularization.”

Dr. Patel then presents data from Benedetto et al. demonstrating that on-pump bypass surgery for left main coronary artery disease in the EXCEL Trial was associated with more extensive revascularization and reduced mortality seemingly related to more complete revascularization. Next, he shows data from the Roma-Verona Registry in Italy showing that more complete revascularization with protected PCI is linked to increased survival.

But should complete revascularization be done in a single setting or staged? Dr. Patel presents data from the BCIS Registry showing that patients who received single-stage complete revascularization had a clear survival benefit compared with propensity-matched patients with only culprit revascularization. In addition, SYNTAX Trial results demonstrated significantly higher all-cause death, urgent revascularization, stroke, and MACCE in patients receiving staged revascularization. The SMILE Trial also demonstrated significantly higher rates of MACCE in patients receiving multi-stage revascularization.

Dr. Patel concludes his presentation by discussing the patient-specific issues as well as operator and cath team considerations that need to be taken into account when considering single versus staged complete revascularization. In this discussion he notes that Impella® can address hemodynamic stability issues and that Impella has been shown to reduce the incidence of acute kidney injury (Flaherty et al. 2017 and Flaherty et al. 2019).

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