Two vessels or not two vessels? That is the question☆
Article Outline
Abstract
Am Heart J 2002; 143:948-9.
See related article on page 1017.
The comparable survival rates for patients with multivessel coronary artery disease treated in randomized trials with either percutaneous intervention or bypass surgery provide the scientific basis to encourage interventional cardiologists to pursue more aggressive revascularization strategies in patients with advanced disease. One area that will need greater clarity is the issue of routine single-setting multivessel intervention versus routine staged therapy. The report of Nikolsky et al in this issue of the Journal is of interest and timely in this regard.
The group from Haifa, Israel, reports in a retrospective analysis on 264 consecutive patients treated over a 2-year period with planned multivessel coronary intervention. Roughly half had all planned lesions treated at the initial setting, and the rest returned on an average of 6 weeks later for completion of revascularization. The authors report similar in-hospital complication rates but more complete revascularization and superior 1-year outcomes in the staged group of patients.
A few comments about the study. Although the authors indicate that these were consecutive patients, an unknown number of patients dropped out of the planned staged approach to therapy. More than half of the patients were selected for staged procedures because of economic considerations defined by the local reimbursement policy in Israel. Only 31% of patients had a physician-driven decision to stage the procedure because of perceived risk, patient comfort, or contrast agent load. These factors would be the major determinants in the United States.
One explanation for the higher complete success rates observed in the staged groups appears to be the outcome of vessels less than 3 mm in diameter. There is no obvious explanation why results would be inferior in smaller vessels treated in single versus staged settings.
Until the time that randomized and prospective studies address the comparative safety and outcome of staged versus single-setting multivessel coronary interventions, operator judgment and experience will be the major factors in decision making. There are factors that influence how many coronary vessels are treated at a single setting. The first of these is informed consent. Patients with multivessel disease can be considered for percutaneous coronary intervention or bypass surgery. If coronary lesions are identified at the time of diagnostic coronary angiography in a patient who has consented for a possible intervention, a judgment must be made by the operator if the patient and family members are adequately informed as to the comparable risks and outcome of catheter-based versus surgical therapies. Patients are often sedated to a degree that they may not be fully able to participate in a serious conversation. In most of these instances, we favor not proceeding with same-setting multivessel intervention and allowing the patient and family to contemplate the options. This is particularly true in patients with diabetes with multivessel disease.
Another factor influencing the amount tackled in a single setting is the contrast load administered. This is a particular factor in combined diagnostic and interventional procedures, patients with multiple bypass grafts needing additional views, and patients with renal insufficiency. Patients with baseline normal renal function can receive high doses of contrast agent with little risk of nephropathy.1 In patients with preexisting renal insufficiency, however, we have identified a contrast agent load of >100 mL as an independent risk factor for contrast nephropathy.2 Attempts to adhere to this limit will exclude most patients with renal insufficiency from single-setting multivessel interventions. In patients with normal baseline renal function, we recommend an awareness of the amount of contrast agent administered and consideration of staging additional lesions when more than 250 to 300 mL has been used.
Fluoroscopic exposure is a factor to be considered in complex and lengthy multivessel procedures. On rare occasions, a single x-ray tube position for long periods of time has resulted in clinically apparent skin burns to patients. In a larger number of lengthy cases, no apparent adverse outcome can be measured, but future risk to the patient from radiation remains a concern. Shielding, shutters to minimize the radiation field, and minimization of angulation may help reduce exposure. A “light foot” on the pedal is prudent.
Patient and physician fatigue is a factor to be considered when multiple vessels are treated at a single setting. Patient comfort can usually be addressed with adequate conscious sedation. Operator fatigue and stress may not be eliminated as easily. Operators may tire or rush towards the end of a long, multivessel procedure and end up with suboptimal results. This may be one explanation for the observation by Nikolsky et al that smaller vessels fared less well in single-setting procedures versus staged treatments. The smaller vessel was likely the last vessel treated and operator “enthusiasm” for perfection may have been at a different level late in the procedure compared with earlier treatments.
A final factor is a real world economic consideration for hospitals. One-vessel procedures average just slightly more than 1 stent per procedure. Multivessel same-setting procedures average well over 2 stents per procedure. In most settings, the reimbursement to hospitals does not adequately cover the increased costs of the additional stents, and they may operate at a loss for these procedures. The impact of this on the viability of a hospital interventional program is a factor to ponder.
The conclusion of any great concern for same-setting multivessel revascularization is premature at this time. Important advantages exist in terms of patient convenience, direct medical costs, hospital stay, and indirect costs, such as lost days of work, with same-setting procedures. There have been advances since the collection of data by Nikolsky et al in the treatment of vessels less than 3 mm with coronary stents. The imminent introduction of drug-coated stents to eliminate restenosis is expected to have a major impact on follow-up event rates from all coronary revascularizations. This study will spur further examinations of results and stategies for greatest patient safety and comfort. Until then, the question of 2 vessels or not 2 vessels can continue to be asked each time we approach a patient with multivessel coronary disease.
References
☆ Reprint requests: William W. O'Neill, MD, William Beaumont Hospital, 3601 W 13 Mile Rd, Royal Oak, MI 48073-6712.
PII: S0002-8703(02)00005-4
doi:10.1067/mhj.2002.122508
© 2002 Mosby, Inc. All rights reserved.
Refers to article:
- Staged versus one-step approach for multivessel percutaneous coronary interventions
