Ten-year all-cause death following percutaneous or surgical revascularization in patients with prior cerebrovascular disease: insights from the SYNTAX Extended Survival study

Rutao Wang, Kuniaki Takahashi, Scot Garg, Daniel J F M Thuijs, Arie Pieter Kappetein, Michael J Mack, Marie-Claude Morice, Friedrich-Wilhelm Mohr, Nick Curzen, Piroze Davierwala, Milan Milojevic, Robert Jan van Geuns, Stuart J Head, Yoshinobu Onuma, David R Holmes Jr, Patrick W Serruys, Rutao Wang, Kuniaki Takahashi, Scot Garg, Daniel J F M Thuijs, Arie Pieter Kappetein, Michael J Mack, Marie-Claude Morice, Friedrich-Wilhelm Mohr, Nick Curzen, Piroze Davierwala, Milan Milojevic, Robert Jan van Geuns, Stuart J Head, Yoshinobu Onuma, David R Holmes Jr, Patrick W Serruys

Abstract

Background: Coronary bypass artery grafting (CABG) has a higher procedural risk of stroke than percutaneous coronary intervention (PCI), but may offer better long-term survival. The optimal revascularization strategy for patients with prior cerebrovascular disease (CEVD) remains unclear.

Methods and results: The SYNTAXES study assessed the vital status out to 10 year of patients with three-vessel disease and/or left main coronary artery disease enrolled in the SYNTAX trial. The relative efficacy of PCI vs. CABG in terms of 10 year all-cause death was assessed according to prior CEVD. The primary endpoint was 10 year all-cause death. The status of prior CEVD was available in 1791 (99.5%) patients, of whom 253 patients had prior CEVD. Patients with prior CEVD were older and had more comorbidities (medically treated diabetes, insulin-dependent diabetes, metabolic syndrome, peripheral vascular disease, chronic obstructive pulmonary disease, impaired renal function, and congestive heart failure), compared with those without prior CEVD. Prior CEVD was an independent predictor of 10 year all-cause death (adjusted HR: 1.35; 95% CI: 1.04-1.73; p = 0.021). Patients with prior CEVD had a significantly higher risk of 10 year all-cause death (41.1 vs. 24.1%; HR: 1.92; 95% CI: 1.54-2.40; p < 0.001). The risk of 10 year all-cause death was similar between patients receiving PCI or CABG irrespective of the presence of prior CEVD (p-interaction = 0.624).

Conclusion: Prior CEVD was associated with a significantly increased risk of 10 year all-cause death which was similar in patients treated with PCI or CABG. These results do not support preferential referral for PCI rather than CABG in patients with prior CEVD.

Trial registration: SYNTAX: ClinicalTrials.gov reference: NCT00114972. SYNTAX Extended Survival: ClinicalTrials.gov reference: NCT03417050.

Keywords: CABG; Cerebrovascular disease; Left main coronary artery disease; PCI; Three-vessel disease.

Conflict of interest statement

Dr. Serruys reports personal fees from Biosensors, Micel Technologies, Sinomedical Sciences Technology, Philips/Volcano, Xeltis, and HeartFlow, outside the submitted work. Dr. Kappetein reports to work as an employee of Medtronic, outside the submitted work. Dr. Head reports to work as a full-time employee of Medtronic outside the scope of this work. Dr. Morice reports to work as the CEO of CERC, a CRO which was never involved in the SYNTAX trial at any level, except that submitted the 10 years additional follow-up (for free) to French authorities to get approval. Dr. van Geuns reports personal fees from Abbott vascular, grants and personal fees from AstraZeneca, grants and personal fees from Amgen, grants and personal fees from Boston Scientific, personal fees from Sanofi, outside the submitted work. All other authors have no disclosures.

© 2021. The Author(s).

Figures

Fig. 1
Fig. 1
Patient flow diagram of the present study. CABG coronary artery bypass grafting, CEVD cerebrovascular disease, PCI percutaneous coronary intervention, TIA transient ischemic attack
Fig. 2
Fig. 2
Kaplan–Meier curves for the primary endpoint of all-cause death up to 10 years in patients without (blue) or with prior CEVD (red). a Overall population; b PCI cohort; c CABG cohort. CABG coronary artery bypass grafting, CEVD cerebrovascular disease, PCI percutaneous coronary intervention

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Source: PubMed

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