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Challenges of Complete Revascularization Faisal Latif, MD FACC FSCAI Associate Professor of Medicine University of Oklahoma Director Cardiac Catheterization Laboratory Complete vs Incomplete Revascularization • Complete CR associated with improved clinical outcomes, compared with incomplete revascularization • However, CR achieved only in: – CABG  75% – PCI  50% Garcia S, Sandoval Y, Roukoz H, et al A meta-analysis of 89,883 patients enrolled in RCTs and observational studies J Am Coll Cardiol 2013;62:1421-31 Bell MR, et al Effect of CR on long-term outcome of patients with three-vessel disease undergoing CABG (CASS registry) Circulation 1992; 86: 446–57 Complete vs Incomplete Revascularization • CABG usually offers complete revascularization • Patients undergoing PCI at times not undergo complete revascularization: – Presence of a CTO – LV dysfunction – Treating the “culprit lesion” only Bell MR, et al Effect of CR on long-term outcome of patients with three-vessel disease undergoing CABG (CASS registry) Circulation 1992; 86: 446–57 Lack of consistent definition for CR Varying Definitions • Most studies use anatomic definitions to define revascularized segment • Definition of significant stenosis has been different: >50% vs >70% • Other definitions take functional significance rather than anatomic What Is Complete Revascularization? Anatomical or Traditional All diseased vessels  1.5 (2.0-2.25 mm for PCI) with > 50% receive a graft (or stent) Functional All ischemic territories are grafted (or stented)- (Except non-viable areas) Numerical Number of distal anastomosis  number of diseased coronary segments/systems Score-based Scoring of stenosis in different vessels Different weight given to different vessels according to number of myocardial segments supplied A residual score of is usually considered equivalent to CR All coronary lesions with FFR ≤ 0.75 -0.80 receive a graft or stent Physiology-Based Duke jeopardy score • Describes extent of CAD based on the amount of myocardium at risk • Coronaries are divided into segments: LAD, largest diagonal, septal branch of the LAD; Circ, OM branch, and PDA • All segments distal to any 75% stenosis, or 50% left main stenosis, are considered to be at risk • Each such segment is assigned points, with a possible maximum of 12/12 or 100% R.M Califf, et al JACC 1985;5:1055–1063 McLellan CS, et al Am Heart J 2005;150:800–6 Complete revascularization • Complete revascularization: post-PCI Duke jeopardy score of or • Incomplete revascularization: post-PCI Duke jeopardy score >2 • Mortality increased in a stepwise fashion as the Duke jeopardy score increased above 2/12 McLellan CS, et al Am Heart J 2005;150:800–6 Clinical Limitations Patient-Related Factors • Advanced age, gender, race • Cardiac comorbidities (LV dysfunction, CHF, prior MI, atrial fibrillation, and prior CABG) • Non-cardiac comorbidities (PAD, renal failure, DM) • MOZART Trial: Minimizing contrast use with IVUS  a significant reduction in total contrast with IVUS guidance over angiography without IVUS (IQR:12-30 ml vs 43-97 ml; p < 0.001) Remember, many of these patients can still have CR with proper planning & techniques Lack of Randomized Controlled Trials The Only RCT! • 219 patients with MVD (and an identified culprit vessel) randomly assigned to CR (>50% lesions) vs culprit-only revascularization • 108 : 111(# of patients) • Primary endpoint: MACE (All-cause death, MI, need for CABG or repeat PCI at year) Ijsselmuiden AJ, et al Am Heart J 2004;148:467-74 The Only RCT! • MACE equal in both: • at 24 hours (6.3% vs 7.4%) • at month (14.4% vs 9.3%) • at year (32.4% vs 26.9%) • at 4.6 years (40.4% vs 34.6%) • Strategy success was higher in the culprit-only compared to CR (93.7% vs 81.5%, P = 007) No benefit & Increased Cost at 1-year But, after 1-year, CR was beneficial and costs equalized Ijsselmuiden AJ, et al Am Heart J 2004;148:467-74 COURAGE • COURAGE Trial: All PCI patients underwent Complete Revascularization • Complete revascularization offers the most suppression of ischemia New York Registry • All patients with MVD who had PCI between Jan 1997 till Dec, 2000 • Exclusions: Patients with previous revasc, LM disease, or MI during the 24-hour period before PCI • CR defined as attempting all lesions with significant stenosis in major coronary arteries • Primary Endpoint: Long-term mortality in patients with MVD who underwent complete vs incomplete revascularization Hannan EL, et al Circulation 2006;113:2406-12 Survival In Complete vs Incomplete Revasc Group 21 945 Patients: 15 128 (68.9%) of these patients underwent “incomplete revascularization” Analysis from SYNTAX Trial • PCI cohort (903 pts) from SYNTAX trial • Residual Syntax score of defined as CR • On average, after PCI score went from – 28.4  4.5 • Residual SYNTAX Score >8 was associated with 35.3% all-cause mortality at 5-years (P