Outcomes of chronic total occlussion recanalization in patients with prior bypass-surgery: an updated systematic review and meta-analysis of real world registries

Abstract

Abstract Background Recanalization of chronic total occlusion (CTO) coronary lesions by percutaneous coronary intervention (PCI) in patients with prior coronary artery bypass grafting (CABG) is still considered a challenging scenario due to the complexity of coronary lesions as well as the requirement of CTO PCI advanced techniques. The aim of this study is to compare clinical outcomes of patients undergoing CTO PCI with and without CABG surgery. Methods We conducted a systematic review and meta-analysis of observational studies that compared in-hospital outcomes of CTO PCI in patients with vs. without prior CABG published in Medline from inception until December 2022. The results are synthesized in a quantitative manner with random effects models. Categorical variables were compared using the chi-square test, whereas continuous variables were compared using a 2-sample Student's t-test. Statistical heterogeneity was assessed by I2 statistics: I2 statistic >50% was considered substantial, and I2 >75% was considered considerable. The Review Manager Software version 5.3.5. (The Cochrane Collaboration, 2014) was used to calculate summary statistics (odds ratios [ORs] with 95% confidence intervals [CIs]). Results Eleven observational studies with a total of 35,666 patients were included, of whom 7,005 patients had a history of CABG. Prior CABG patients were older, (68.1 ± 9.0 vs. 64.1 ± 10.7 years; p < 0.001), and had more complex coronary lesions (J-CTO score: 3.2 ± 1.4 vs. 2.5 ± 1.4; p < 0.001). Prior CABG was associated with lower technical success (66.6% vs. 78.5%; OR 0.53 [95% CI: 0.43 to 0.65]; p < 0.00001, I2 = 84%) as well as lower procedural success (OR 0.64 [95% CI: 0.57 to 0.71]; p < 0.00001, I2 = 0%) as compared with patients with no prior CABG (Figure 1A and Figure 1B). Prior CABG patients had a higher incidence of in-hospital mortality (0.7% vs. 0.4%; OR: 2.00 [95% CI: 1.32 to 3.05]; p = 0.001, I2 = 9%, Figure 2A), coronary perforation (3.7% vs. 2.3%; OR: 1.64 [95% CI: 1.15 to 2.33]; p < 0.006, I2 = 74%, Figure 2B), and myocardial infarction (1.7% vs. 0.7%; OR: 2.57 [95% CI: 1.73 to 3.81]; p < 0.00001, I2 = 12%), but a lower incidence of cardiac tamponade (0.2% vs. 0.9%; OR: 0.36 [95% CI: 0.17 to 0.77]; p = 0.09, I2 = 0%, Figure 2C) compared with those without prior CABG. Both groups had a similar incidence of acute cerebrovascular events (0.2% vs. 0.1%; OR: 1.70 [95% CI: 0.75 to 3.88]; p = 0.21, I2 = 0%), major bleeding (1.4% vs. 1.2%; OR: 1.24 [95% CI: 0.96 to 1.61]; p = 0.09, I2 = 0%) and vascular complications (1.4% vs. 0.9%; OR: 1.50 [95% CI: 0.93 to 2.41]; p = 0.10, I2 = 0%). Conclusion Prior CABG patients undergoing CTO PCI presented a higher risk of in-hospital mortality and perioperative procedural complications although the risk of tamponade was lower.Figure 1A and Figure 1BFigure 2A, 2B and 2C