title: The negative impact of incomplete angiographic revascularization on clinical outcomes and its association with total occlusions: the SYNTAX (Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery) trial.
abstract: OBJECTIVE
  The study sought to evaluate the clinical impact of angiographic complete (CR) and incomplete (ICR) revascularization and its association with the presence of total occlusions (TO), after percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery in the "all-comers" SYNTAX (Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery) trial.
  
  
  BACKGROUND
  In patients with complex coronary artery disease undergoing PCI or CABG, the long-term prognostic implications of CR versus ICR is unsettled.
  
  
  METHODS
  In this post hoc study, consisting of randomized (n = 1,800) and nested PCI (n = 198) and CABG (n = 649) registries, 4-year clinical outcomes were compared in groups, with and without angiographic CR, in the PCI and CABG arms. Clinical outcomes were analyzed with Kaplan-Meier estimates, log-rank comparisons, and Cox regression analyses. Multivariate predictors of ICR were determined. Similar analyses were undertaken in the TO and non-TO treated groups of both study arms.
  
  
  RESULTS
  Angiographic CR was achieved in 52.8% of the PCI arm and 66.9% of the CABG arm. Within the PCI and CABG arms, ICR (compared with CR) seemed to be a surrogate marker of a greater burden of anatomical coronary complexity and clinical comorbidity and was associated with significantly higher frequencies of 4-year mortality, all-cause revascularization, stent thrombosis (PCI arm), and major adverse cardiac and cerebrovascular events. The presence of a TO was the strongest independent predictor of ICR after PCI (hazard ratio: 2.70, 95% confidence interval: 1.98 to 3.67, p < 0.001). Eight hundred and forty patients (PCI: 26.3%, CABG: 36.4%, p < 0.001) were identified to have 1,007 TOs, with 68.1% of TOs located in the proximal-mid coronary vasculature. The findings associating ICR (compared with CR) with higher frequencies of 4-year mortality and major adverse cardiac and cerebrovascular events remained consistent in the TO-treated groups in the PCI and CABG arms.
  
  
  CONCLUSIONS
  Within the PCI and CABG arms of the all-comers SYNTAX trial, angiographically determined ICR has a detrimental impact on long-term clinical outcomes, including mortality. This effect remained consistent in patients with and without TOs.
authors.affiliation: Department of Interventional Cardiology, Erasmus University Medical Centre, Thoraxcenter, Rotterdam, the Netherlands.
authors.forename: Vasim
authors.initials: V
authors.lastname: Farooq
authors.forename: Patrick W
authors.initials: PW
authors.lastname: Serruys
authors.forename: Hector M
authors.initials: HM
authors.lastname: Garcia-Garcia
authors.forename: Yaojun
authors.initials: Y
authors.lastname: Zhang
authors.forename: Christos V
authors.initials: CV
authors.lastname: Bourantas
authors.forename: David R
authors.initials: DR
authors.lastname: Holmes
authors.forename: Michael
authors.initials: M
authors.lastname: Mack
authors.forename: Ted
authors.initials: T
authors.lastname: Feldman
authors.forename: Marie-Claude
authors.initials: MC
authors.lastname: Morice
authors.forename: Elisabeth
authors.initials: E
authors.lastname: Ståhle
authors.forename: Stefan
authors.initials: S
authors.lastname: James
authors.forename: Antonio
authors.initials: A
authors.lastname: Colombo
authors.forename: Roberto
authors.initials: R
authors.lastname: Diletti
authors.forename: Michail I
authors.initials: MI
authors.lastname: Papafaklis
authors.forename: Ton
authors.initials: T
authors.lastname: de Vries
authors.forename: Marie-Angèle
authors.initials: MA
authors.lastname: Morel
authors.forename: Gerrit Anne
authors.initials: GA
authors.lastname: van Es
authors.forename: Friedrich W
authors.initials: FW
authors.lastname: Mohr
authors.forename: Keith D
authors.initials: KD
authors.lastname: Dawkins
authors.forename: Arie-Pieter
authors.initials: AP
authors.lastname: Kappetein
authors.forename: Georgios
authors.initials: G
authors.lastname: Sianos
authors.forename: Eric
authors.initials: E
authors.lastname: Boersma
mesh_terms: D000368:Aged; D015906:Angioplasty, Balloon, Coronary; D017023:Coronary Angiography; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D054059:Coronary Occlusion / Q000000981:diagnostic imaging / Q000628:therapy; D003328:Coronary Thrombosis / Q000453:epidemiology; D005260:Female; D006083:Graft Occlusion, Vascular / Q000453:epidemiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D057216:Propensity Score; D015607:Stents / Q000009:adverse effects; D016896:Treatment Outcome