Lesion characteristics and procedural complications of chronic total occlusion percutaneous coronary intervention in patients with prior bypass surgery: A meta-analysis

Coronary artery bypass graft (CABG) accelerates the prevalence of native coronary chronic total occlusion (CTO), and this kind of CTO shows extensive challenging and complex atherosclerotic pathology. As a result, the procedural success rate of percutaneous coronary intervention (PCI) is inferior to another kind of lesions. The present meta-analysis aims to compare the lesion characteristics and procedural complications of CTO-PCI in patients with or without prior CABG. A total of 8 studies, comprising of 13439 patients, published from inception to August 2021 were included in this meta-analysis. Results were pooled using random effects model and are presented as odds ratio (OR) with 95% confidence intervals (95% CIs). From the 13439 patients enrolled, 3349 (24.9%) patients had previous CABG and 10090 (75.1%) formed the control group in our analysis. For the clinical characteristic, compared to the non-CABG patients, prior CABG patients were older (OR, 3.98; 95% CI, 3.19-4.78; p < .001; I-2 = 72%), had more male (OR, 1.30; 95% CI, 1.14-1.49; p < .001; I-2 = 6%), diabetes mellitus (OR, 1.54; 95% CI, 1.36-1.73; p < .001; I-2 = 37%), dyslipidemia (OR, 1.89; 95% CI, 1.33-2.69; p < .001; I-2 = 81%), hypertension (OR, 1.88; 95% CI, 1.46-2.41; p < .001; I-2 = 71%), previous myocardial infarction (OR, 1.94; 95% CI, 1.48-2.56; p < .001; I-2 = 85%), and previous PCI (OR, 1.74; 95% CI, 1.52-1.98; p < .001; I-2 = 22%). Non-CABG patents had more current smoker (OR, .45; 95% CI, 0.27-0.74; p < .001; I-2 = 91%). BMI (OR, -0.01; 95% CI, -0.07-0.06; p = .85; I-2 = 36%) were similar in both groups. For lesions location, the right coronary artery (RCA) was predominant target vessel in both groups (50.5% vs 48.7%; p = .49), although, the left circumflex (LCX) was more frequently CTO in the prior CABG group (27.3% vs 18.9%; p< 0.01), while left anterior descending artery (LAD) in non-CABG ones (16.0% vs 29.1%; p< .0.01). For lesions characteristics, prior CABG patients had more blunt stump (OR, 1.71; 95% CI, 1.46-2.00; p < .001; I-2 = 40%), proximal cap ambiguity (OR, 1.45; 95% CI, 1.28-1.64; p < .001; I-2 = 0.0%), severe calcifications (OR, 2.91; 95% CI, 2.19-3.86; p < .001; I-2 = 83%), more bending (OR, 3.07; 95% CI, 2.61-3.62; p < .001; I-2 = 0%), lesion length > 20 mm (OR, 1.59; 95% CI, 1.10-2.29; p = .01; I-2 = 83%), inadequate distal landing zone (OR, 1.95; 95% CI, 1.75-2.18; p<.001; I-2 = 0.0%), distal cap at bifurcation (OR, 1.65; 95% CI, 1.46-1.88; p < .001; I-2 = 0.0%), and higher J-CTO score (SMD, 0.52; 95% CI, 0.42-0.63; p < .001; I-2 = 65%). But side branch at proximal entry (OR, 0.88; 95% CI, 0.72-1.07; p = .21; I-2 = 45%), in-stent CTO (OR, 0.99; 95% CI, 0.86-1.14; p = .88; I-2 = 0.0%), lack of interventional collaterals (OR, 0.80; 95% CI, 0.55-1.15; p = .23; I-2 = 78%), and previously failed attempt (OR, 0.73; 95% CI, 0.48-1.11; p = .14; I-2 = 89%) were similar in both groups. For complication, prior CABG patients had more perforation with need for intervention (OR, 1.91; 95% CI, 1.36-2.69; p < 0.001; I-2 = 34%), contrast-induced nephropathy (OR, 3.40; 95% CI, 1.31-8.78; p = .01; I-2 = 0.0%). Non-CABG patents had more tamponade (OR, 0.25; 95% CI, 0.09-0.72; p = .01; I-2 = 0.0%), and the major bleeding complication (OR, 1.18; 95% CI, 0.57-2.44; p = . 65; I-2 = 0%) were no significant difference in both groups. In conclusion, Patients with prior CABG undergoing CTO-PCI have more complex lesion characteristics, though procedural complication rates were comparable.