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Impact of complete revascularization on long-term clinical outcomes for patients with diabetes mellitus and coronary chronic total occlusion lesion

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Abstract

Diabetes mellitus (DM) is a substantial risk factor in developing coronary artery disease (CAD), coronary chronic total occlusion (CTO) lesions are discovering 10–35% in patients who underwent coronary angiography. This study compares the long-term clinical outcomes of two treatment strategies, percutaneous coronary intervention (PCI) with complete recanalization versus medication therapy (MT) with CTO lesion in DM patients with CTO. This study is a single-center, prospective, all-comer registry designed to reflect “real world” practice since 2004. Of a total of 4909 consecutive patients were diagnosed with significant CAD by coronary angiography (CAG). A total of 372 patients has DM and CTO lesions. Patients were divided into the PCI group (n = 184) and the MT group (n = 179). The primary endpoint, defined as the composite of death or myocardial infarction (MI), was compared between the two groups up to 5 years. In addition, inverse probability weighting (IPTW) analysis, derived from the logistic regression model, was performed to adjust for potential confounders. Compared to the MT group, the PCI group was associated with a significantly reduced incidence of the primary endpoint before [hazard ratio; HR 0.267, 95% confidence interval (CI) 0.116–0.614] and after (HR 0.142, 95% CI 0.032–0.629) adjusting confounding factors by IPTW. Complete revascularization by CTO-PCI with MT in DM patients should be the preferred treatment strategy compared with the MT alone strategy since it reduces the composite of death or MI up to 5 years.

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Abbreviations

CABG:

Coronary artery bypass graft

CAD:

Coronary artery disease

CAG:

Coronary angiography

CI:

Confidence interval

CTO:

Chronic total occlusion

DM:

Diabetes mellitus

EF:

Ejection fraction

HR:

Hazard ratio

IPTW:

Inverse probability weighting

ISR:

In-stent restenosis

KUGH:

Korea University Guro Hospital

LAD:

Left anterior descending

LCX:

Left circumflex

LM:

Left main

LV:

Left ventricular

MACE:

Major adverse cardiac events

MI:

Myocardial infarction

MT:

Medication therapy

PCI:

Percutaneous coronary intervention

RCA:

Right coronary artery

TIMI:

Thrombolysis in myocardial infarction

TLR:

Target lesion revascularization

TVR:

Target vessel revascularization

References

  1. Grantham JA, Marso SP, Spertus J, House J, Holmes DR Jr, Rutherford BD (2009) Chronic total occlusion angioplasty in the United States. JACC Cardiovasc Interv 2(6):479–486

    Article  Google Scholar 

  2. Hoye A, van Domburg RT, Sonnenschein K, Serruys PW (2005) Percutaneous coronary intervention for chronic total occlusions: the Thoraxcenter experience 1992–2002. Eur Heart J 26(24):2630–2636

    Article  Google Scholar 

  3. Suero JA, Marso SP, Jones PG, Laster SB, Huber KC, Giorgi LV, Johnson WL, Rutherford BD (2001) Procedural outcomes and long-term survival among patients undergoing percutaneous coronary intervention of a chronic total occlusion in native coronary arteries: a 20-year experience. J Am Coll Cardiol 38(2):409–414

    Article  CAS  Google Scholar 

  4. Valenti R, Migliorini A, Signorini U, Vergara R, Parodi G, Carrabba N, Cerisano G, Antoniucci D (2008) Impact of complete revascularization with percutaneous coronary intervention on survival in patients with at least one chronic total occlusion. Eur Heart J 29(19):2336–2342

    Article  Google Scholar 

  5. Kahn JK (1993) Angiographic suitability for catheter revascularization of total coronary occlusions in patients from a community hospital setting. Am Heart J 126(3 Pt 1):561–564

    Article  CAS  Google Scholar 

  6. Puma JA, Sketch MH Jr, Tcheng JE, Harrington RA, Phillips HR, Stack RS, Califf RM (1995) Percutaneous revascularization of chronic coronary occlusions: an overview. J Am Coll Cardiol 26(1):1–11

    Article  CAS  Google Scholar 

  7. Ruygrok PN, De Jaegere PP, Verploegh JJ, Van Domburg RT, De Feyter PJ (1995) Immediate outcome following coronary angioplasty. A contemporary single centre audit. Eur Heart J 16 Suppl L:24–29

  8. Hwang JW, Yang JH, Choi SH, Hwang JK, Jang WJ, Hahn JY, Song YB, Choi JH, Lee SH, Gwon HC (2016) Optimal medical therapy may be a better initial strategy in patients with chronic total occlusion of a single coronary artery. Int J Cardiol 210:56–62

    Article  Google Scholar 

  9. Gray WA, Feiring A, Cioppi M, Hibbard R, Gray B, Khatib Y, Jessup D, Bachinsky W, Rivera E, Tauth J, Patarca R, Massaro J, Stoll HP, Jaff MR, Investigators SS (2015) S.M.A.R.T. self-expanding nitinol stent for the treatment of atherosclerotic lesions in the superficial femoral artery (STROLL): 1-year outcomes. J Vasc Interv Radiol 26(1):21–28

  10. Olivari Z, Rubartelli P, Piscione F, Ettori F, Fontanelli A, Salemme L, Giachero C, Di Mario C, Gabrielli G, Spedicato L, Bedogni F, Investigators T-G (2003) Immediate results and one-year clinical outcome after percutaneous coronary interventions in chronic total occlusions: data from a multicenter, prospective, observational study (TOAST-GISE). J Am Coll Cardiol 41(10):1672–1678

    Article  Google Scholar 

  11. Rha SW, Choi BG, Choi SY, Choi CU, Gwon HC, Chae IH, Kim HS, Park HS, Lee SH, Kim MH, Hur SH, Jang Y, Registry KC (2020) Multicenter experience with percutaneous coronary intervention for chronic total occlusion in Korean population: analysis of the Korean nationwide multicenter chronic total occlusion registry. Coron Artery Dis 31(4):319–326

    Article  Google Scholar 

  12. Frye RL, August P, Brooks MM, Hardison RM, Kelsey SF, MacGregor JM, Orchard TJ, Chaitman BR, Genuth SM, Goldberg SH, Hlatky MA, Jones TL, Molitch ME, Nesto RW, Sako EY, Sobel BE (2009) A randomized trial of therapies for type 2 diabetes and coronary artery disease. N Engl J Med 360(24):2503–2515

    Article  CAS  Google Scholar 

  13. Choi D, Kim SK, Choi SH, Ko YG, Ahn CW, Jang Y, Lim SK, Lee HC, Cha BS (2004) Preventative effects of rosiglitazone on restenosis after coronary stent implantation in patients with type 2 diabetes. Diabetes Care 27(11):2654–2660

    Article  CAS  Google Scholar 

  14. Choi JY, Choi BG, Rha SW, Mashaly A, Abdelshafi K, Choi CU, Yu CW, Gwon HC, Chae IH, Kim HS, Sik Park H, Lee SH, Kim MH, Hur SH, Jang Y (2020) One-year clinical outcomes of coronary chronic total occlusion intervention in patients with acute coronary syndrome versus stable angina: from the Korean chronic total occlusion registry. Coron Artery Dis 31(5):430–437

    Article  Google Scholar 

  15. Choi SY, Choi BG, Rha SW, Baek MJ, Ryu YG, Park Y, Byun JK, Shim M, Li H, Mashaly A, Jang WY, Kim W, Choi JY, Park EJ, Na JO, Choi CU, Lim HE, Kim EJ, Park CG, Seo HS, Oh DJ (2017) Percutaneous Coronary Intervention Versus Optimal Medical Therapy for Chronic Total Coronary Occlusion With Well-Developed Collaterals. J Am Heart Assoc 6(9)

  16. Park JY, Choi BG, Rha SW, Kang TS, Choi CU, Yu CW, Gwon HC, Chae IH, Kim HS, Park HS, Lee SH, Kim MH, Hur SH, Jang Y (2018) Chronic total occlusion intervention of the non-infarct-related artery in acute myocardial infarction patients: the Korean multicenter chronic total occlusion registry. Coron Artery Dis 29(6):495–501

    Article  Google Scholar 

  17. Rha SW, Choi BG, Baek MJ, Ryu YG, Li H, Choi SY, Byun JK, Mashaly A, Park Y, Jang WY, Kim W, Choi JY, Park EJ, Na JO, Choi CU, Lim HE, Kim EJ, Park CG, Seo HS, Oh DJ (2018) Five-year outcomes of successful percutaneous coronary intervention with drug-eluting stents versus medical therapy for chronic total occlusions. Yonsei Med J 59(5):602–610

    Article  Google Scholar 

  18. Jang WJ, Yang JH, Choi SH, Song YB, Hahn JY, Choi JH, Kim WS, Lee YT, Gwon HC (2015) Long-term survival benefit of revascularization compared with medical therapy in patients with coronary chronic total occlusion and well-developed collateral circulation. JACC Cardiovasc Interv 8(2):271–279

    Article  Google Scholar 

  19. Voudris VA, Skoularigis JS, Dimitriou YK, Grapsa GN, Malakos JS, Pavlides GS, Manginas AN, Cokkinos DV (2004) Diabetes mellitus and unstable coronary artery disease: improved clinical outcome of coronary artery stenting in an era of glycoprotein IIb/IIIa inhibitors and lipid-lowering therapy. Coron Artery Dis 15(6):353–359

    Article  Google Scholar 

  20. Bulugahapitiya U, Siyambalapitiya S, Sithole J, Idris I (2009) Is diabetes a coronary risk equivalent? Systematic review and meta-analysis Diabet Med 26(2):142–148

    CAS  PubMed  Google Scholar 

  21. Paneni F, Beckman JA, Creager MA, Cosentino F (2013) Diabetes and vascular disease: pathophysiology, clinical consequences, and medical therapy: part I. Eur Heart J 34(31):2436–2443

    Article  CAS  Google Scholar 

  22. Christofferson RD, Lehmann KG, Martin GV, Every N, Caldwell JH, Kapadia SR (2005) Effect of chronic total coronary occlusion on treatment strategy. Am J Cardiol 95(9):1088–1091

    Article  Google Scholar 

  23. Damluji AA, Pomenti SF, Ramireddy A, Al-Damluji MS, Alfonso CE, Schob AH, Marso SP, Gilchrist IC, Moscucci M, Kandzari DE, Cohen MG (2016) Influence of Total Coronary Occlusion on Clinical Outcomes (from the Bypass Angioplasty Revascularization Investigation 2 DiabetesTrial). Am J Cardiol 117(7):1031–1038

    Article  Google Scholar 

  24. Hoye A (2012) Management of chronic total occlusion by percutaneous coronary intervention. Heart 98(10):822–828

    Article  Google Scholar 

  25. Galassi AR, Boukhris M, Azzarelli S, Castaing M, Marza F, Tomasello SD (2016) Percutaneous coronary revascularization for chronic total occlusions: a novel predictive score of technical failure using advanced technologies. JACC Cardiovasc Interv 9(9):911–922

    Article  Google Scholar 

  26. Claessen BE, Dangas GD, Godino C, Henriques JP, Leon MB, Park SJ, Stone GW, Moses JW, Colombo A, Mehran R, Multinational CTOR (2013) Impact of target vessel on long-term survival after percutaneous coronary intervention for chronic total occlusions. Catheter Cardiovasc Interv 82(1):76–82

    Article  Google Scholar 

  27. Galassi AR, Tomasello SD, Reifart N, Werner GS, Sianos G, Bonnier H, Sievert H, Ehladad S, Bufe A, Shofer J, Gershlick A, Hildick-Smith D, Escaned J, Erglis A, Sheiban I, Thuesen L, Serra A, Christiansen E, Buettner A, Costanzo L, Barrano G, Di Mario C (2011) In-hospital outcomes of percutaneous coronary intervention in patients with chronic total occlusion: insights from the ERCTO (European Registry of Chronic Total Occlusion) registry. EuroIntervention 7(4):472–479

    Article  Google Scholar 

  28. Morino Y, Abe M, Morimoto T, Kimura T, Hayashi Y, Muramatsu T, Ochiai M, Noguchi Y, Kato K, Shibata Y, Hiasa Y, Doi O, Yamashita T, Hinohara T, Tanaka H, Mitsudo K, Investigators JCR (2011) Predicting successful guidewire crossing through chronic total occlusion of native coronary lesions within 30 minutes: the J-CTO (Multicenter CTO Registry in Japan) score as a difficulty grading and time assessment tool. JACC Cardiovasc Interv 4(2):213–221

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Author notes

  1. Seung-Woon Rha and Hu Li are the first authors.

Authors and Affiliations

  1. Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea

    Seung-Woon Rha & Cheol Ung Choi

  2. Cardiovascular Department, The Second Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China

    Hu Li

  3. Cardiovascular Research Institute, Korea University, 198, Gamasan-ro, Guro-gu, Seoul, 08309, Republic of Korea

    Byoung Geol Choi

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  1. Seung-Woon Rha
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  2. Hu Li
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Contributions

SWR, HL, and BGC researched data and wrote the manuscript. SWR and BGC contributed to the study design. BGC contributed to the collection of research data. CCU contributed to provide intellectual inputs for the discussion. BGC contributed to data analysis and edited the manuscript. All authors take full responsibility for this work.

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Correspondence to Seung-Woon Rha or Byoung Geol Choi.

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Rha, SW., Li, H., Choi, C.U. et al. Impact of complete revascularization on long-term clinical outcomes for patients with diabetes mellitus and coronary chronic total occlusion lesion. Heart Vessels 37, 1679–1688 (2022). https://doi.org/10.1007/s00380-022-02079-y

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  • DOI: https://doi.org/10.1007/s00380-022-02079-y

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