Short-Term Outcomes of Revascularization for Chronic Total Occlusions in Multivessel Coronary Artery Disease: Does Coronary Artery Bypass Grafting (CABG) Beat Percutaneous Coronary Intervention (PCI) in Acute Hospital Settings?

introductionChronic total occlusions (CTO) are commonly associated with multivessel coronary disease (MVD). Although coronary artery revascularization via percutaneous coronary intervention (PCI) has demonstrated better outcomes than medical therapy alone for single-vessel disease in various clinical trials, the best approach to revascularization in MVD remains complex and less explored. This observational study compared the acute in-hospital outcomes of PCI and coronary artery bypass grafting (CABG) in the revascularization of chronic total occlusion with multivessel disease. Considering the minimally invasive nature of PCI compared to CABG, we hypothesized that PCI would correlate with fewer acute in-hospital complications and a shorter length of hospital stay than CABG for chronic total occlusion in the acute hospital setting.

methodsWe analyzed 151,270 hospitalizations for CTO with MVD across the U.S from the 2017 to 2022 national inpatient sample registry. Approximately 105,925 (70%) hospitalizations underwent PCI and 45,345 (30%) underwent CABG. Propensity score matching was used to alleviate the residual bias from non-randomized treatment assignments. Mortality and complication rates were compared using the McNemar's test. Hospital stay duration and total costs were compared using paired sample t-tests or Wilcoxon rank-sum tests.

resultsThe study cohort consisted of 101,141 men (66.2%) and 104,830 White Americans (69.3%), with a median age of 74 years (interquartile range [IQR], 65-82). All hospitalizations in this cohort were associated with an estimated 10-year mortality rate of 25% or less (Charlson Comorbidity Index [CCI] score ≥3). The matched cohort was comprised of 9,210 CABGs and 9,210 PCIs. All covariate imbalances were alleviated. Compared to PCI, CABG was associated with higher mortality (442, 4.8% vs. 313, 33.4%; P=0.003), longer hospital stay (15 vs. 5 days; P<0.001), and higher hospitalization costs (mean: $320,917 ±$24,158 vs. $129,396 ± $7,234; P<0.001). CABG also showed higher postprocedural incidences of acute ischemic stroke (157, 1.7% vs. 111, 1.2%; P=0.008), complete atrioventricular block (147, 1.6% vs. 111, 1.2%; P=0.035), sepsis (332, 3.6% vs. 166, 1.8%; P<0.001), atrial flutter (1,649 [17.9%] vs. 635 [6.9%]; P<0.001), atrial fibrillation (3,039 [33%] vs. 1,382 [15%]; P<0.001), and ventricular fibrillation (193 [2.1%] vs. 129 [1.4%]; P=0.046). However, repeat acute myocardial infarction rates were lower with CABG than with PCI (2.7% vs. 4.3%; P<0.001).

conclusionPCI was associated with lower in-hospital mortality, shorter duration of hospitalization, and decreased hospitalization costs compared to CABG. Conversely, CABG was linked to lower rates of recurrent myocardial infarction but exhibited higher incidences of acute postprocedural arrhythmias, stroke, and sepsis.