The dueling hazards of incomplete revascularization and incomplete data.

Although the survival benefit of complete revascularization after bypass surgery is well documented, the importance of opening all stenotic or occluded vessels during percutaneous coronary intervention (PCI) is less certain. On the contrary, much data support targeting only the culprit vessel during PCI. A strategy of “ischemic-driven revascularization” is often the standard of care. Through a potpourri of noninvasive imaging (eg, nuclear imaging, positron emission tomography, stress echocardiography), as well as invasive techniques (eg, fractional flow reserve, intravascular ultrasound measurements, quantitative angiography), much effort has gone into identifying the functional importance of coronary blockages and confining intervention to diseased vessels that significantly limit blood flow to viable myocardium.1,2 Indeed, the phrase oculostenotic reflex was invented to describe the indiscriminate interventionalist, bent on opening any suspicious angiographic blockage. This subcortical reflex has long been considered a liability, and interventionalists are taught to be more cerebral in their decision making. In this issue of Circulation, Hannan et al, in a very provocative report, use data from the New York State reporting system to turn decades of teaching on its ear.3 Using a database created from a State of New York reporting registry, procedural information was collected on 21 945 patients with 2-vessel coronary artery disease undergoing stenting. Then, using patient’s Social Security numbers, these in-hospital data were correlated with the New York State Vital Statistics Death File to capture mortality events over a follow-up period of 3 years. The study found that patients with incomplete revascularization (after adjustment for baseline differences) were 15% more likely to die at follow-up than patients with complete revascularization. This mortality risk increased with the degree of incomplete revascularization. Patients with 1 unopened total occlusion were 35% more likely to die. If 2 vessels were incompletely revascularized, and at least 1 of them was totally occluded, the risk of death was 36% higher. A finding of only 1 incompletely revascularized vessel without a total occlusion did not increase the risk of subsequent mortality. The authors conclude that in patients receiving stents, incomplete revascularization results in increased mortality, and therefore cardiologists should consider either “achieving complete revascularization, opting for surgery, or monitoring PCI patients with incomplete revascularization more closely after discharge.”