Читать книгу Practical Cardiovascular Medicine - Elias B. Hanna - Страница 210

Complete revascularization is defined as revascularization of all functionally significant stenoses in vessels ≥1.5 mm supplying viable territories. However, this has been defined differently across studies, and some based it on angiographic disease >50–70% rather than on functionally significant disease, or on achieving revascularization of the three major epicardial vessels (as opposed to all branches).⁹³ CABG generally achieves more complete revascularization than PCI, as it is less affected by lesion complexity (e.g., CTO) (67% vs. 53% in SYNTAX trial).⁹⁴ In most registries and post-hoc analyses, incomplete revascularization was associated with impaired outcomes only after PCI (New York and ARTS registries).^95,96 This adverse outcome may be related to the residual disease itself, or more so, to the fact that residual disease is a marker of more extensive and aggressive atherosclerosis even across the revascularized arteries, which explains why incomplete revascularization is more unfavorable after PCI, which only treats focal disease, than after CABG. In fact, the intense pursuit of complete revascularization may not, by itself, improve outcomes. In two analyses of CABG patients, incomplete revascularization of a small/poor target RCA or LCx in patients receiving LIMA-to-LAD graft did not adversely affect long-term outcomes; in fact, too aggressive revascularization of >1 non-LAD vessel may be associated with worse outcomes.^97,98 This is called “reasonable” incomplete revascularization. This reasonable revascularization concept fits with the functional revascularization concept where only large and ischemic territories are revascularized. Incomplete revascularization usually has a worse connotation with PCI than with CABG, as (i) PCI is a suboptimal therapy for extensive disease, and (ii) PCI more frequently omits large, otherwise graftable vessels because of technical challenge, such as CTO.