ORIGINAL ARTICLE Impact of prior coronary artery bypass graft surgery on chronic total occlusion revascularisation: insights from a multicentre US registry Tesfaldet T Michael, 1,2 Dimitri Karmpaliotis, 3 Emmanouil S Brilakis, 1,2 Shuaib M Abdullah, 1,2 Ben L Kirkland, 3 Katrina L Mishoe, 4 Nicholas Lembo, 3 Anna Kalynych, 3 Harold Carlson, 3 Subhash Banerjee, 1,2 William Lombardi, 4 David E Kandzari 3 1 Department of Internal Medicine/Cardiology, VA North Texas Healthcare System, Dallas, Texas, USA 2 Department of Internal Medicine/Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA 3 Department of Cardiology, Piedmont Heart Institute, Atlanta, Georgia, USA 4 Department of Cardiology, St. Joseph Hospital, Bellingham, Washington, USA Correspondence to Dr Emmanouil S Brilakis, Dallas VA Medical Center (111A), 4500 South Lancaster Road, Dallas, TX 75216, USA; esbrilakis@yahoo.com Received 5 February 2013 Revised 18 March 2013 Accepted 19 March 2013 Published Online First 18 April 2013 ▸ http://dx.doi.org/10.1136/ heartjnl-2013-304521 To cite: Michael TT, Karmpaliotis D, Brilakis ES, et al. Heart 2013;99:1515– 1518. ABSTRACT Objective To investigate the impact of prior coronary artery bypass graft (CABG) surgery on the outcomes of percutaneous coronary intervention (PCI) for chronic total occlusions (CTO). Design Observational retrospective study. Setting Three tertiary hospitals in the USA. Participants 1363 consecutive patients who underwent CTO PCI between 2006 and 2011. Main outcome measures Procedural success and inhospital complications, which were compared between patients with and without prior CABG. Results Compared to patients without prior CABG, those with prior CABG were older, had more comorbidities, were treated more frequently with the retrograde approach (46.7% vs 27.1%, p<0.001) and had lower technical success rates (79.7% vs 88.3%, p=0.015). Of the 24 (1.8%) major inhospital complications, 11 occurred in patients with prior CABG and 13 in patients without prior CABG (2.1% vs 1.5%, p=0.392). In multivariable analysis prior CABG was independently associated with lower technical success rate (OR 0.49, 95% CIs 0.35 to 0.70, p<0.001). Conclusions In a large multicentre registry, CTO PCI was frequently performed among patients with prior CABG, with higher use of the retrograde approach and similar complications but lower technical success rates compared to patients without prior CABG. INTRODUCTION Patients with prior coronary artery bypass graft (CABG) surgery often have complex coronary anatomy, (a) because complex coronary atheroscler- osis may have led to the earlier decision for CABG, and (b) because CABG can accelerate the develop- ment of coronary atherosclerosis. 12 Approximately half the patients with prior CABG undergoing cor- onary angiography have a coronary chronic total occlusion (CTO). 3 Patients with prior CABG often develop recurrent symptoms and events due to development of saphenous vein graft disease or progression of native coronary atherosclerosis. 4 5 Percutaneous coronary intervention (PCI) of native coronary arteries is preferred as revascularisation strategy among these patients, especially those with patent left internal artery bypass grafts, given the increased risk of saphenous vein graft interventions 6 and the fact that repeat CABG is technically difficult, has higher mortality compared with initial CABG and provides less symptomatic improvement. 7 However, procedural success with CTO PCI is challenged among patients with prior CABG by lesion complexity that limits both antegrade and retrograde strategies. 8 In the present study we sought to characterise the prevalence of CTO PCI and outcomes in this subgroup of interest, especially as it represents an increasing fraction of CTO PCI. 9 METHODS Patient population We performed a retrospective review ofthe proced- ural and clinical records of consecutive patients who underwent CTO PCI between January 2006 and November 2011 at three US centres: St Joseph Medical Center, Bellingham, Washington, USA; Piedmont Heart Institute, Atlanta, Georgia, USA; and VA North Texas Healthcare System, Dallas, Texas, USA. The study was approved by the institu- tional review board of each institution. Study endpoints and definitions Coronary CTOs were defined as angiographic evi- dence of a total occlusion with thrombolysis in myocardial infarction grade 0 or grade 1 and esti- mated duration of at least 3 months. Estimation of occlusion duration was based upon first onset of angina, prior history of myocardial infarction in the target vessel territory or comparison with a prior angiogram. Patients were considered to have had retrograde CTO PCI if a guide wire was introduced into a collateral channel that supplied the target CTO vessel distal to the lesion. Procedural success was defined as achievement of technical success with no inhospital major adverse cardiac events (MACE). Technical success was defined as successful CTO recanalisation with achievement of <50% residual diameter stenosis within the treated segment and restoration of thrombolysis in myocardial infarction grade 3 ante- grade flow. Inhospital MACE included any of the following adverse events prior to hospital dis- charge: Q wave myocardial infarction, recurrent angina requiring urgent repeat target vessel revascu- larisation with PCI or coronary bypass surgery, Editor’s choice Scan to access more free content Michael TT, et al. Heart 2013;99:1515–1518. doi:10.1136/heartjnl-2013-303763 1515 Coronary revascularisation group.bmj.com on April 27, 2016 - Published by http://heart.bmj.com/ Downloaded from