Lesion Characteristics and Procedural​ Complications of Chronic Total Occlusion Percutaneous Coronary Intervention in Patients with Prior Bypass Surgery: A Meta-analysis

Abstract BACKGROUND: Coronary artery bypass graft (CABG) accelerates the prevalence of native coronary chronic total occlusion (CTO), and this kind of CTO shows more advanced and complex atherosclerotic pathology. As a result, the procedural success rate of percutaneous coronary intervention (PCI) is inferior to another kind of lesions. The present meta-analysis aims to compare the lesion characteristics and procedural complications of CTO-PCI in patients with or without prior CABG.METHODS: A total of 8 studies, comprising of 13439 patients, published from inception to August 2021 were included in this meta-analysis. Results were pooled using random effects model and are presented as odds ratio (OR) with 95% confidence intervals (95% CIs). RESULTS: From the 13439 patients enrolled, 3349 (24.9%) patients had previous CABG and 10090 (75.1%) formed the control group in our analysis. For the clinical characteristic, compared to the non-CABG patents, prior CABG patients were older (OR, 3.98; 95% CI, 3.19-4.78; P<0.001; I2=72%), had more male (OR, 1.30; 95% CI, 1.14-1.49; P<0.001; I2=6%), diabetes mellitus (OR, 1.54; 95% CI, 1.36-1.73; P<0.001; I2=37%), dyslipidemia (OR, 1.89; 95% CI, 1.33-2.69; P<0.001; I2=81%), hypertension (OR, 1.88; 95% CI, 1.46-2.41; P<0.001; I2=71%), previous myocardial infarction (OR, 1.94; 95% CI, 1.48-2.56; P<0.001; I2=85%), and previous PCI (OR, 1.74; 95% CI, 1.52-1.98; P<0.001; I2=22%). Non-CABG patents had more current smoker (OR, 0.45; 95% CI, 0.27-0.74; P<0.001; I2=91%). BMI (OR, -0.01; 95% CI, -0.07-0.06; P=0.85; I2=36%) were similar in both groups. For lesions location, the right coronary artery (RCA) was predominant target vessel in both groups (50.5% vs 48.7%; P＝0.49), although, the left circumflex (LCX) was more frequently CTO in the prior CABG group (27.3% vs 18.9%; P＜0.01), while left anterior descending artery (LAD) in non-CABG ones (16.0% vs 29.1%; P＜0.01). For lesions characteristics, prior CABG patients had more blunt stump (OR, 1.71; 95% CI, 1.46-2.00; P<0.001; I2=40%), proximal cap ambiguity (OR, 1.45; 95% CI, 1.28-1.64; P<0.001; I2=0.0%), severe calcifications (OR, 2.91; 95% CI, 2.19-3.86; P<0.001; I2=83%), more bending (OR, 3.07; 95% CI, 2.61-3.62; P<0.001; I2=0%), lesion length > 20 mm (OR, 1.59; 95% CI, 1.10-2.29; P=0.01; I2=83%), inadequate distal landing zone (OR, 1.95; 95% CI, 1.75-2.18; P＜0.001; I2=0.0%), distal cap at bifurcation (OR, 1.65; 95% CI, 1.46-1.88; P<0.001; I2=0.0%), and higher J-CTO score (SMD, 0.52; 95% CI, 0.42-0.63; P<0.001; I2=65%). But side branch at proximal entry (OR, 0.88; 95% CI, 0.72-1.07; P=0.21; I2 =45%), in-stent CTO (OR, 0.99; 95% CI, 0.86-1.14; P=0.88; I2=0.0%), lack of interventional collaterals (OR, 0.80; 95% CI, 0.55-1.15; P=0.23; I2=78%), and previously failed attempt (OR, 0.73; 95% CI, 0.48-1.11; P=0.14; I2=89%) were similar in both groups. For complication, prior CABG patients had more perforation with need for intervention (OR, 1.91; 95% CI, 1.36-2.69; P<0.001; I2=34%), contrast-induced nephropathy (OR, 3.40; 95% CI, 1.31-8.78; P=0.01; I2=0.0%). Non-CABG patents had more tamponade (OR, 0.25; 95% CI, 0.09-0.72; P=0.01; I2=0.0%), and the major bleeding complication (OR, 1.18; 95% CI, 0.57-2.44; P=0.65; I2=0%) were no significant difference in both groups.CONCLUSION: Patients undergoing CTO-PCI with prior CABG have more complex lesion characteristics, though procedural complication rates were comparable.