But, as Dr. Lorenzo Azzalini told Reuters Health by email, "In-stent CTO PCI has similar success and in-hospital MACE rates as CTO PCI in native arteries. However, it is associated with higher 1-year MACE rates, highlighting the inferior patency rates of PCI for ISR, similar to what is observed in all-comers with non-occlusive in-stent restenosis."
Dr. Azzalini of Virginia Commonwealth University, in Richmond, and colleagues examined data on close to 12,000 CTO-PCIs performed in 11,728 patients at 107 centers between 2012 and 2020.
Altogether ISR CTOs accounted for 15% of total cases, they report in JACC: Cardiovascular Interventions. These patients had a significantly higher prevalence of diabetes and prior coronary-artery-bypass-graft surgery. They also had a higher J-CTO score, but technical and procedural success was similar for both ISR and de novo CTOs. This was also true of in-hospital MACE, which was seen in 1.7% of the ISR group and 2.2% of the de novo patients (P=0.25).
However, say the researchers, "As anticipated, patients who underwent PCI of in-stent CTOs had higher incidence MACE during follow-up driven by higher incidence of target-vessel revascularization."
After a median follow-up of 12 months in the more than 5,700 patients for whom data were available, those with ISR CTOs had a higher incidence of MACE (hazard ratio, 1.31; P=0.04) and target-vessel revascularization (HR, 1.34; P=0.05). However, there were similar between-group rates of myocardial infarction and death.
Among limitations of the study, say the researchers, were that relevant data on the type of the occluded stent in the ISR CTO group and alternative treatments to stenting, such as drug-coated balloons and brachytherapy as well as baseline medical therapy, were not available.
The study "represents an example to follow for future research collaborations in the field, which would be of particular interest, for example, to describe rare complications such as radiation skin injury or infrequent anatomic subsets of CTO PCI," concluded Dr. Azzalini.
Dr. Ziyad Ghazzal, author of an accompanying editorial, told Reuters Health by email, "In-stent chronic total coronary occlusion is a challenging lesion subset. This analysis of four multicenter registries reported similar high success rates with percutaneous coronary intervention of in-stent and de novo chronic total occlusions."
Dr. Ghazzal, of the American University of Beirut, Lebanon, added, "The advancement in technology as well as the growing numbers of dedicated centers of excellence has contributed to an improved outcome. Nevertheless, experienced operators should always rely on clear indications for revascularization."
SOURCE: https://bit.ly/3x5zbP5 and https://bit.ly/2ReOUfc JACC: Cardiovascular Interventions, online May 26, 2021.
By David Douglas
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