Outcomes after complete versus incomplete revascularization of patients with multivessel coronary artery disease: a meta-analysis of 89,883 patients enrolled in randomized clinical trials and observational studies

Abstract

Objectives: This study sought to perform a systematic review and meta-analysis of studies comparing complete revascularization (CR) versus incomplete revascularization (IR) in patients with multivessel coronary artery disease.

Background: There are conflicting data regarding the benefits of CR in patients with multivessel coronary artery disease.

Methods: We identified observational studies and subgroup analysis of randomized clinical trials (RCT) published in PubMed from 1970 through September 2012 using the following keywords: "percutaneous coronary intervention" (PCI); "coronary artery bypass graft" (CABG); "complete revascularization"; and "incomplete revascularization." Main outcome measures were total mortality, myocardial infarction, and repeat revascularization procedures.

Results: We identified 35 studies including 89,883 patients, of whom 45,417 (50.5%) received CR and 44,466 (49.5%) received IR. IR was more common after PCI than after CABG (56% vs. 25%; p < 0.001). Relative to IR, CR was associated with lower long-term mortality (risk ratio [RR]: 0.71, 95% confidence interval [CI]: 0.65 to 0.77; p < 0.001), myocardial infarction (RR: 0.78, 95% CI: 0.68 to 0.90; p = 0.001), and repeat coronary revascularization (RR: 0.74, 95% CI: 0.65 to 0.83; p < 0.001). The mortality benefit associated with CR was consistent across studies irrespective of revascularization modality (CABG: RR: 0.70, 95% CI: 0.61 to 0.80; p < 0.001; and PCI: RR: 0.72, 95% CI: 0.64 to 0.81; p < 0.001) and definition of CR (anatomic definition: RR: 0.73, 95% CI: 0.67 to 0.79; p < 0.001; and nonanatomic definition: RR: 0.57, 95% CI: 0.36 to 0.89; p = 0.014).

Conclusions: CR is achieved more commonly with CABG than with PCI. Among patients with multivessel coronary artery disease, CR may be the optimal revascularization strategy.

Keywords: CABG; CAD; CI; CR; CTO; FFR; IR; MI; OR; PCI; RCT; RR; chronic total occlusion; complete revascularization; confidence interval; coronary artery bypass graft; coronary artery bypass surgery; coronary artery disease; fractional-flow reserve; incomplete revascularization; meta-analysis; myocardial infarction; odds ratio; percutaneous coronary intervention; randomized clinical trial; risk ratio.