‘Simple’ Approach to Repeat PCI Safe, Successful at 4 Years in Unprotected LM Disease

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Repeat percutaneous coronary intervention (PCI) can be performed safely and with a high rate of procedural success in the small percentage of patients with unprotected distal left main disease who require it after PCI with a drug-eluting stent (DES). The registry findings, publihed online January 15, 2014, ahead of print in JACC: Cardiovascular Interventions, show that a simple strategy for in-stent restenosis was associated with low long-term event rates.

Soledad Ojeda, MD, PhD, of University of Córdoba (Córdoba, Spain), and colleagues looked at 1,102 consecutive patients with lesions involving the unprotected sdistal left main coronary artery treated with DES at 2 high-volume centers between May 2002 and February 2011. At angiographic follow-up conducted at the occurrence of symptoms or signs of ischemia, 79 patients (7%) had in-stent restenosis, 75 of whom were treated with repeat PCI.

Patients underwent repeat PCI using a simple strategy of in-stent implantation (n = 31) or balloon angioplasty (n = 13) or a complex strategy of  1 (n = 22) or 2 (n = 9) additional stents implanted.

Good Long-Term Outcomes

There was high in-hospital procedural success with repeat PCI with only 2 patients experiencing non-Q-wave MI and 3 deaths (4%), attributable to heart failure (n = 2) and cardiogenic shock (n = 1).

At a mean follow-up of 46 months, MACE (cardiac death, MI, and TLR) was 22%, with a higher incidence in patients who underwent a complex vs. simple in-stent restenosis approach (table 1).

Table 1. Outcomes by In-stent Restenosis Approach

 

Simple Approach
(n = 44)

Complex Approach
(n = 31)

P Value

MACE-Free Survival

85%

53%

< 0.05

TLR-Free Survival

97%

63%

< 0.05


Additionally, patients with in-stent restenosis affecting only 1 bifurcation segment had higher MACE-free survival compared with patients with > 1 segment involved (84% vs. 47%; P < 0.05).

Regardless of how many bifurcation segments for which a patient underwent repeat PCI, use of a simple strategy resulted in improved TLR- and MACE-free survival (table 2).

Table 2. Outcomes by Extent of Restenosis, In-Stent Restenosis Approach

 

Simple Approach(n = 44)

Complex Approach
(n = 31)

P Value

One Affected Bifurcation Segment
MACE-Free Survival
TLR-Free Survival

 
93%
96%

 
67%
67%

 
< 0.05
< 0.05

> 1 Affected Bifurcation Segment
MACE-Free Survival
TLR-Free Survival

 

70%
100%

 
23%
50%

 
< 0.05
< 0.05


About half (49%) of the patient population had diabetes at baseline. The researchers identified diabetes as the only independent predictor of increased MACE (HR 4.94; 95% CI 1.03-23.70; P < 0.05). In contrast, the use of a simple approach was an independent predictor of less MACE (HR 0.25; 95% CI 0.08-0.79; P = 0.02).

Keep it Simple

In a telephone interview with TCTMD, Jeffrey W. Moses, MD, of Columbia University Medical Center/Weill Cornell Medical Center (New York, NY), called the 7% clinical restenosis rate astonishingly low when considering 9 years of left main procedures.

Dr. Ojeda and colleagues acknowledged that the low rate of restenosis made it difficult to obtain a large sample size and reduced the ability to control for potentially confounding variables.

Despite that, Dr. Moses commented that the 5% bypass rate shows “just how effective this treatment is in this population.”

Additionally, Dr. Ojeda and colleagues pointed out that the restenosis treatment modality was left to the discretion of the operator, meaning no definitive conclusions on the ideal restenosis technique can be drawn from these results.

However, Dr. Moses observed that the results should prompt operators to keep procedures straightforward when repeat procedures are necessary. “Even when looking at a simple presentation and a simple strategy in the multivariate analysis, it turned out at the end of the day that the strategy dominates as the principle technical driver of long-term outcomes,” he said. “Our general instinct should be to keep restenosis treatment as simple as possible.”

 


Source:
Ojeda S, Pan M, Martín P, et al. Immediate results and long-term clinical outcome of patients with unprotected distal left main restenosis: The CORPAL (Córdoba and Les Palmas) registry. J Am Coll Cardiol Intv. 2014;Epub ahead of print.

 

 

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Disclosures
  • Dr. Ojeda reports no relevant conflicts of interest.
  • Dr. Moses reports consulting for Abbott Vascular and Boston Scientific.

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