What Is the Optimal Revascularization Strategy in Patients With Cerebrovascular Disease?

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Data from the EXCEL trial do not currently support a preferential role for PCI as opposed to CABG in patients with prior cerebrovascular disease.
Data from the EXCEL trial do not currently support a preferential role for PCI as opposed to CABG in patients with prior cerebrovascular disease.

Individuals with left main coronary artery disease (LMCAD) and previous cerebrovascular disease have higher rates of stroke and reduced post-revascularization event-free survival rates than those without cerebrovascular disease, according to analysis of the Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL) study, published in JACC: Cardiovascular Interventions.

However, although periprocedural stroke occurs less frequently after percutaneous coronary intervention (PCI) than after coronary artery bypass grafting (CABG), data from the EXCEL trial do not currently support a preferential role for PCI as opposed to CABG in patients with prior cerebrovascular disease.

This study included 1905 participants in the EXCEL trial (ClinicalTrials.gov Identifier: NCT01205776). Patients with scores ≤32 on Synergy Between PCI with Taxus and Cardiac Surgery (SYNTAX) and LMCAD were randomly assigned to either coronary artery bypass grafting or percutaneous coronary intervention with everolimus-eluting stents.

Definitions of previous cerebrovascular disease included transient ischemic attack, stroke, and carotid artery disease, and its effects were studied with 1-month to 3-year event rates. Primary end points included periprocedural stroke rate at 1 month and the rates of stroke and composite all-cause death/myocardial infarction/stroke at 3 years.

Of the 1898 participants included in the final study, 12.3% (n=233) had previous cerebrovascular disease, which was associated with older age; lower body mass index; and higher rates of comorbid diabetes, hypertension, anemia, peripheral vascular disease, chronic kidney disease, and previous percutaneous coronary intervention.

Previous cerebrovascular disease was also associated with a 2.2% rate of stroke at 30 days, compared with 0.8% among those without (=.05), as well as a higher 3-year rate of stroke (6.4% vs 2.2%; =.0003) and composite all-cause death/myocardial infarction/stroke (25% vs 13.6%; <.0001).

No difference was observed between those with and without previous cerebrovascular disease in terms of primary composite end point rates at 3 years (=.14) and effects of coronary artery bypass grafting compared with percutaneous coronary intervention on 1-month (=.65) and 3-year (=.16) stroke rates.

Limitations to this study included potential confounders, a lack of subgroup analysis, and a lack of result applicability to those with more acute neurological problems or recent symptoms.

The study researchers concluded that "although periprocedural stroke occurs less frequently after PCI than CABG, data from EXCEL do not support a preferential role of PCI over CABG in patients with known [cerebrovascular disease]”.

Several authors report financial and consulting associations with pharmaceutical companies. For a full list of author disclosures, see the reference.

Reference

Diamond J, Madhavan MV, Sabik III JF, et al. Left main percutaneous coronary intervention versus coronary artery bypass grafting in patients with prior cerebrovascular disease: results from the EXCEL trial  [published online December 18, 2018]. JACC Cardiovasc Interv. doi: 10.1210/jc.2018-00578

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