Content uploaded by Mark M Gallagher
Author content
All content in this area was uploaded by Mark M Gallagher on Apr 05, 2018
Content may be subject to copyright.
Revascularization strategy in patients with multivessel disease
and a major vessel chronically occluded; data from the CABRI trial
Eugenio Martuscelli
a,
*, Fabrizio Clementi
a
, Mark M. Gallagher
a
, Alessia D’Eliseo
a
,
Gaetano Chiricolo
a
, Antonio Nigri
b
, Benedetto Marino
b
, Francesco Romeo
a
and on behalf of CABRI trialists
a
Department of Cardiology, University of Rome ‘‘Tor Vergata’’, Italy
b
Department of Cardiac Surgery, University of Rome ‘‘La Sapienza’’, Italy
Received 30 May 2007; received in revised form 21 August 2007; accepted 27 September 2007; Available online 7 November 2007
Abstract
Objective: In patients with multivessel coronary artery disease and total occlusion of major epicardial vessel, completeness of revasculariza-
tion has not been investigated in specific trials comparing the surgical and the percutaneous revascularization strategy. Analyzing the database of
the CABRI study, which randomized a substantial number of these patients, we investigated the long-term effects of a successful or unsuccessful
revascularization of the occluded vessel and completeness of the revascularization. Methods and results: The CABRI study randomized 1054
patients with multivessel coronary disease to coronary bypass or to coronary angioplasty. From the database of this trial, we selected patients
with a major vessel chronically occluded (103 in the bypass group and 120 in the angioplasty group). At a median follow-up of 30 months, the
incidence of death or Q-wave myocardial infarction (combined end point) was significantly lower in the bypass group than in the angioplasty group
(6.8% vs 17.5%, respectively; hazard ratio [HR], 0.42 [95% CI 0.17—0.98]; p= 0.047). On univariate analysis, age, proximal occlusion, complete
revascularization, revascularization of the occluded vessel and revascularization procedure were identified as significant predictors of combined
end points. On multivariate analysis, independent predictors of combined end points resulted in completeness of revascularization (HR 0.26; 95%
CI 0.09—0.76; p= 0.01) and age (HR 1.07; 95% CI 1.02—1.12; p<0.01). Conclusion: In patients with multivessel coronary disease and chronic
occlusion of a major epicardial vessel, achieving of a complete revascularization by reopening or bypassing the occluded vessel is associated with
a significantly better long-term prognosis.
#2007 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.
Keywords: Incomplete revascularization; Percutaneous coronary angioplasty; Coronary artery bypass; Chronic coronary occlusion
1. Introduction
Patients with a chronic occlusion of a major epicardial
vessel and significant narrowing of one or both of the other
coronary arteries represent a special problem in the choice of
revascularization strategy. Until recently, coronary artery
bypass grafting (CABG) was considered to be the treatment of
choice in such patients as it provided complete revascular-
ization more frequently than percutaneous transluminal
coronary angioplasty (PTCA) [1]. With current techniques
and equipment, the probability of reopening a chronic total
occlusion by PTCA has increased substantially [2]. Many
interventional cardiologists now choose to deal with such
patients by PTCA, believing that the long-term clinical
outcome is similar to that of surgery in terms of survival
and acute myocardial infarction (AMI) occurrence. They draw
support from randomized trials comparing surgery and
coronary angioplasty in patients with multivessel coronary
disease [3—8] though none of these trials were designed to
address this question. Several randomized trials have
compared the outcome of CABG and PTCA in multivessel
coronary artery disease, but none of these specifically
addressed the importance of a totally occluded major
epicardial artery. Equivalence of revascularization was
mandatory in some trials [3—6], effectively excluding patients
with a chronic total occlusion who were considered too
difficult to revascularize by PTCA in that era. In other trials
the entry criteria did not exclude patients with a chronically
occluded vessel [7], but such patients were recruited in
numbers too few to analyze as a separate subgroup.
In the CABRI trial, 1054 patients with symptomatic
multivessel coronary disease were randomized to PTCA or
CABG [8]. The CABRI trial did not require equivalence of
revascularization for study enrolment. Patients with a
chronically occluded major vessel were considered eligible
www.elsevier.com/locate/ejcts
European Journal of Cardio-thoracic Surgery 33 (2008) 4—8
* Corresponding author. Address: University of Rome ‘‘Tor Vergata’’, Depart-
ment of Cardiology, Viale Oxford 81, 00133 Rome, Italy.
Tel.: +39 0620903996; fax: +39 0620904043.
E-mail address: e.martuscelli@libero.it (E. Martuscelli).
1010-7940/$ — see front matter #2007 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.ejcts.2007.09.029
if at least one lesion in another vessel was considered to be
amenable to PTCA. The CABRI cohort therefore included a
substantial population of patients whose multivessel cor-
onary disease included a chronic total occlusion of a major
epicardial vessel.
From the database of the CABRI study, we selected all
patients with chronic occlusion of a major coronary vessel
with the aim of determining whether the success of
revascularization in the territory of this vessel would
influence the long-term outcome regardless of the revascu-
larization strategy.
2. Methods
2.1. Study population and data collection
The CABRI trial [8] enrolled 1054 patients in 26 centers
throughout Europe over 53 months from July 1988. All
patients undergoing coronary angiography who needed
revascularization were evaluated for eligibility. Patients
with single vessel coronary disease were excluded, as were
those with left main coronary disease or severe triple vessel
disease (defined as ‘last remaining vessel’, equivalent to two
occluded main epicardial vessel), ejection fraction <0.35,
overt cardiac failure, an acute myocardial infarction within
the previous 10 days, or previous revascularization proce-
dure. Patients with severe concomitant cardiac or non-
cardiac illness likely to affect short-term survival were also
excluded. Lesions suitable for PTCA could include total and
subtotal occlusions.
At the time of the CABRI trial, PTCA implied balloon
angioplasty alone in most cases, with stent implantation used
as a back up in case of difficulties. Cardiac surgery was carried
out usually on cardiopulmonary bypass and inclusionin the trial
did not impose on the surgeon any restriction in the use of
arterial or venous conduits. Only those patients for whom both
cardiologists and surgeons believed could achieve clinical
improvement by PTCA or CABG were randomized.
Of the patients recruited on the basis of these criteria, 541
were randomly assigned to PTCA and 513 to CABG. Annual
clinical assessment for 10 years was planned and follow-up
cardiac catheterization was planned as a single event 12
months after randomization. The two strategies of revascu-
larization were compared on the basis of intention to treat,
having as primary outcome mortality and symptom status at 1
year. Secondary outcomes were myocardial infarction,
requirement for medications and repeat revascularization
procedures.
From the CABRI database we selected all patients with
chronic occlusion of one of the three major coronary vessels
(left anterior descending artery, circumflex artery or right
coronary artery). Of the 223 persons meeting these criteria,
121 were initially randomized to PTCA and 102 to CABG.
2.2. Baseline clinical variables
At the time of enrollment and at 1 year follow-up, clinical
symptom status was assessed in terms of angina graded
according to the Canadian Cardiovascular Society class, and
dyspnea graded according to the New York Heart Association
class. Left ventricular function was assessed by ventriculo-
graphy. A history of hypercholesterolemia (total cholesterol
of 6.5 mmol/l and/or lipid lowering treatment) systemic
hypertension (blood pressure 160/90 mmHg and/or hyper-
tensive treatment), cerebrovascular disease or peripheral
vascular disease was recorded. Myocardial infarction was
defined by the presence of a clinical history of myocardial
infarction and/or the presence of abnormal Q-waves on the
12-lead electrocardiogram.
2.3. Coronary disease variables
The angiographic criteria for trial suitability required a
>50% reduction of luminal diameter viewed from two
projections in two or more major epicardial vessels. At least
one lesion had to be suitable for PTCA and the vessel distal to
the lesion had to be at least 2 mm in diameter. Patients with
chronic total occlusion were admitted if at least one lesion on
another major vessel was suitable for PTCA. For the purposes
of analysis, multivessel disease was defined as two or three
native vessels with significant disease excluding the left main
coronary artery.
2.4. Completeness of revascularization
Before randomization, cardiologists and surgeons identi-
fied target vessels, suitable for revascularization by PTCA or
CABG. In patients randomized to PTCA, revascularization was
considered complete if, in the target vessels, every lesion
>50% could be dilated successfully (final diameter reduction
<50%). In patients randomized to CABG, revascularization
was considered complete if every target vessel received a
venous or an arterial conduit.
2.5. Study objectives and statistical methods
The primary aim of our analysis was to compare estimated
hazard ratio for the composite endpoint of death or Q-wave
myocardial infarction during a median period of 30 months of
follow-up after revascularization. Using SPSS 13 software
(SPSS Inc., Chicago, Illinois), independent variables were
cross tabulated by treatment randomization to check
comparability of treatment groups. Associations were tested
for using unpaired ttests for continuous data with a normal
distribution, Mann—Whitney U-test for continuous data not
normally distributed and x
2
tests for categorical data. Event-
free survival from death or Q-wave myocardial infarction was
estimated by the Kaplan—Meier method, and differences in
the two treatment groups were assessed by means of the log-
rank test. Analysis of predictors of 50 months death or Q-
wave myocardial infarction was performed with Cox propor-
tional hazards regression with stepwise selection and entry
criteria of p= 0.05 and exit criteria of p= 0.1. The
proportional hazard assumption was confirmed. Patients lost
to follow-up were considered at risk until the date of last
contact, at which point they were censored. Bivariate
correlation coefficients between variables were also com-
puted to identify colinearity. When the correlation coeffi-
cient between two variables was >0.6, only 1 was selected in
the final model. The selection was based on the results of the
univariate analysis and taking into account the significance
E. Martuscelli et al. / European Journal of Cardio-thoracic Surgery 33 (2008) 4—8 5
level. The variables considered as possible predictors
included: occluded vessel, occluded vessel revasculariza-
tion, proximal median or distal occlusion, occluded vessel,
left-ventricular ejection fraction, treatment group (PTCA/
CABG), diabetes, previous AMI, angina class, ejection
fraction, active smoker, hypercholesterolemia, hyperten-
sion, peripheral vascular disease and previous cerebro-
vascular accident. Only variables with an association <0.1 in
the univariate model were considered for multivariate
analysis. All analyses were based on the intention-to-treat
principle. All tests of significance were two sided. A
probability value <0.05 was considered significant.
3. Results
Patients randomized to PTCA and CABG were closely
matched for clinical and angiographic characteristics
(Table 1). Mean follow-up was 30.7 and 28.1 months for
PTCA and CABG, respectively. Death occurred in 12.5%
(n= 15) of the PTCA group compared with 4.9% (n= 5) of the
CABG group ( p= ns) (Table 2). The mortality for the entire
population of the CABRI study has been reported to be, in the
4 year follow-up, 10.9% in PTCA patients and 7.4% in CABG
patients ( p= ns) [9]. Non-fatal Q-wave myocardial infarction
occurred in 6.7% (n= 8) of the PTCA group and in 2.9% (n=3)
of the CABG group ( p= ns). The incidence of the composite
endpoint of death or Q-wave myocardial infarction was
significantly lower in the CABG group than in the PTCA group
(6.8% vs 17.5%, respectively; hazard ratio [HR], 0.42 [95% CI
0.17—0.98]; p= 0.047) (Table 2,Fig. 1).
Of the patients initially randomized to PTCA, 46.7%
(n= 56) required a second revascularization and 10% (n= 12)
a third revascularization; the cross over to surgery was 30.8%
(n= 37) (Table 2). A successful dilatation of the totally
occluded vessel occurred in 11.7% of the patients in PTCA
group; whereas the occlusion was successfully bypassed in
76.5% of the patients revascularized by CABG (OR 26.3; 95% CI
12.7—54.3; p<0.001) (Table 2). A complete revasculariza-
tion was achieved in 7.5% of the patients randomized to PTCA
versus 72.8% of the patients randomized to CABG (OR 33.0;
95% CI 14.7—73.9; p<0.001) (Table 2). On univariate
analysis, age, proximal occlusion, complete revasculariza-
tion, revascularization of the occluded vessel and revascu-
larization procedure were identified as significant predictors
of the composite end points (Table 3,Figs. 1—3). On
multivariate analysis, the only independent predictors of
E. Martuscelli et al. / European Journal of Cardio-thoracic Surgery 33 (2008) 4—8
6
Table 1
Characteristics of patients at randomization
CABG (n= 103) PTCA (n= 120) p
Age 58 (9) 60 (9) ns
Gender, M 84.5% 90.0% ns
EF 60 (11) 61 (12) ns
Angina grade
1 13.6% 15.9% ns
2 20.4% 23.5%
3 38.8% 37.0%
4 27.2% 23.5%
NYHA class
1 70.9% 74.1% ns
2 23.3% 21.7%
3 5.8% 4.2%
Previous myocardial infarction 54.4% 47.5% ns
Diabetes 16.5% 10.8% ns
Hypercholesterolemia 52.4% 46.7% ns
Smoker 56.3% 49.2% ns
Hypertension 37.9% 26.7% ns
PVD 8.7% 6.7% ns
Vessel occluded
CX 17.5% 24.2% ns
RC 62.1% 55.8%
LAD 20.4% 20.0%
Baseline characteristic, functional status and location of the major vessel
occluded in patients randomized to CABG or PTCA.
Table 2
Thirty months outcomes
CABG
(n= 103) (%)
PTCA
(n= 120) (%)
p
Q-wave Myocardial Infarction 2.9 (3) 6.7 (8) ns
Death 4.9 (5) 12.5 (15) 0.06
Death or Q-wave
myocardial infarction
6.8 (7) 17.5 (21) 0.05
Angina grade
1 89.3 83.7 ns
2 8.7 12.1
3 1.9 4.3
NYHA class
1 87.3 82.7 ns
2 7.8 11.2
3 3.9 6.0
4 1.0 0
28Intervention
CABG 0 25.0 (30) <0.01
PTCA 5.8 (6) 21.7 (26)
38Intervention
CABG 0 5.8 (7) <0.05
PTCA 1.0 (1) 4.2 (5)
Revascularization of occluded vessel 77.5 11.7 <0.01
Completeness of revascularization 72.8 7.5 <0.01
Clinical outcome, successful revascularization of the vessel occluded and
completeness of revascularization at 30 months follow-up in patients sub-
mitted to PTCA or CABG.
Fig. 1. Event-free survival from death and Q-wave myocardial infarction at 50
months of follow-up estimated by the Kaplan—Meier method in patients
submitted to CABG (dotted lines) or PTCA (solid lines).
combined events were completeness of revascularization and
patient age (Table 3).
4. Discussion
The revascularization of patients with multiple vessel
disease including the chronic occlusion of a major vessel has
not been specifically addressed in a randomized trial. Our
analysis of this subgroup of patients in the CABRI trial
indicates that at the time of that trial, surgery gave a better
outcome in these patients in terms of subsequent mortality
and risk of AMI. The superiority of CABG over PTCA was
attributable to a greater probability of complete revascular-
ization when surgery was used. Multiple surgical series have
clearly shown that completeness of revascularization is
associated with better long-term results in terms of mortality
and risk of AMI [10,11].
In the case of PTCA, there are conflicting data regarding
the importance of completeness of revascularization.
Bourassa et al., using data from the National Heart, Lung,
and Blood Institute percutaneous Transluminal Coronary
Angioplasty Registry, showed that the adjusted risk of
mortality at 9 years was independent of the completeness
of revascularization. Patients with incomplete revascular-
ization by PTCA were more likely to subsequently undergo
CABG (32 vs 14%, p<0.001) [12]. Similar results were found
in the Arterial Revascularization Study (ARTS) trial [13]. More
recently, Hannan et al. compared the long-term outcome of
21,925 patients revascularized by PTCA [14]. Patients with
incomplete revascularization had a significantly higher
mortality and the worst rate of survival was found in patients
with a major epicardial coronary artery totally occluded.
These results are in agreement with results obtained by
Ivanhoe et al. [15], Suero et al. [16], Olivari et al. [17]. They
showed that a revascularization procedure, which includes
the successful opening of the occluded vessel, is associated
with a better outcome in terms of survival and AMI
occurrence. A possible explanation of this is that a PTCA
that treats one or two vessels but leaves another vessel
occluded exposes the patient to dramatic consequences if
the treated vessel occludes suddenly. In a study by Puma
et al. [18], 2216 patients with chronic occlusion of a single
vessel were followed to determine the natural history of this
condition. Freedom from death and AMI was low at 3 years
(87%) and very low at 15 years (52%); the authors concluded
that the mortality rate in this population might still be
considered to be excessive in the long term, suggesting that
the occluded vessel might exert a deleterious effect beyond
what would be expected.
Our study addresses the question of the best option in the
revascularization strategy of patients with multivessel
coronary disease involving the total occlusion of a major
vessel, a subgroup commonly encountered in clinical practice
but poorly represented in the randomized trials. Our data
clearly show that completeness of revascularization is the
only independent predictor of the combined end point of
mortality and AMI (HR 0.26; 95% CI 0.09—0.76); a complete
revascularization was obtained in our study much more
frequently in the surgical group than in the PTCA group,
principally due to the frequent failure of PTCA in the
revascularization of the occluded vessel.
Successful opening of a chronically occluded coronary
vessel is still a challenge in the patient with multiple vessel
E. Martuscelli et al. / European Journal of Cardio-thoracic Surgery 33 (2008) 4—8 7
Tabl e 3
Univariate and multivariate Cox proportional hazard analysis
Variables pHazard ratio (95% CI) x
2
Univariate analysis
Age 0.03 1.07 (1.04—1.125) 8.8
Proximal occlusion 0.03 2.47 (1.09—5.63) 5.0
Complete revascularization 0.019 0.28 (0.09—0.81) 7.2
Revascularization of the occluded vessel 0.047 0.40 (0.16—0.98) 4.5
CABG versus PTCA 0.047 0.42 (0.17—0.98) 4.0
Multivariate analysis
Complete revascularization 0.01 0.26 (0.09—0.76) 6.7
Age 0.004 1.07 (1.02—1.12) 9.2
Univariate and multivariate Cox proportional hazard analysis for death and
acute myocardial infarction. Revascularization of the occluded vessel was not
included in the multivariate model because of colinearity with complete
revascularization.
Fig. 2. Event-free survival from death and Q-wave myocardial infarction at 50
months follow-up estimated by the Kaplan—Meier method, in patients with
successful (solid lines) or unsuccessful (dotted lines) revascularization of the
vessel occluded.
Fig. 3. Event-free survival from death and Q-wave myocardial infarction at 50
months follow-up estimated by the Kaplan—Meier method, in patients with
complete (solid lines) or incomplete revascularization (dotted lines).
disease. The rate of procedural success in the 1990s was
between 46% and 75% depending on the number of vessels
diseased and on the location of the occlusion, with the worst
results obtained in patients with triple vessel disease and
occlusion of the right coronary artery [15]. More recent
advances including the use of special dedicated guidewires
have substantially increased the procedural success [2], but
the real cost benefit of such procedures in large series or
randomized trials is unknown.
In our study, coronary stenting was used as a back up
procedure in patients with poor immediate angiographic
results or in case of acute post procedural vessel closure. This
can be considered a limitation of our study.
In the years since the study, techniques of percutaneous
intervention have evolved with a great expansion in the use
of stents, and recently with the introduction of drug eluting
stents. In spite of the limited techniques available at the
time, the composite end point of death or AMI in the overall
CABRI population was not influenced by the revascularization
strategy, showing that percutaneous revascularization by
traditional methods can be as effective as the surgery in
multivessel disease without total occlusion.
This is confirmed by the 5 year follow-up of the
BENESTENT trial [19] which showed that mortality and AMI
occurrence were similar ( p= ns) in patients revascularized
by balloon PTCA or stent PTCA.
A recent meta-analysis comparing bare and drug eluting
stents [20] has further confirmed that new endocoronary
devices can substantially reduce the need for a subsequent
revascularization without any significant modification of the
composite end points as mortality and AMI.
Data regarding the viability of the myocardium in the
territory of the occluded vessel were not available; and this
can be considered another limitation of the study; therefore
it was impossible to assess the long-term effects of the
revascularization depending on the presence of viable
myocardium. Patients with a chronically occluded major
artery were admitted to randomization if at least one lesion
was suitable for PTCA and, above all, if cardiologists and
surgeons believed that they could achieve clinical improve-
ment by PTCA or CABG.
5. Conclusions
Our study shows that in patients with multivessel coronary
disease including the chronic occlusion of a major epicardial
vessel, surgery can offer a higher probability of full
revascularization and a higher probability of remaining alive
and free of AMI in the long term. If a percutaneous
revascularization strategy is attempted, every effort must
be made to reopen the occluded vessel and obtain complete
revascularization. If this proves impossible, a surgical
approach should be reconsidered.
References
[1] Ong AT, Serruys PW. Complete revascularization: coronary artery bypass
graft surgery versus percutaneous coronary intervention. Circulation
2006;114(3):249—55.
[2] Surmely JF, Tsuchikane E, Katoh O, Nishida Y, Nakayama M, Nakamura S,
Oida A, Hattori E, Suzuki T. New concept for Cto recanalization using
controlled antegrade and retrograde subintimal tracking: the Cart tech-
nique. J Invasive Cardiol 2006;18(7):334—8.
[3] Rodriguez A, Boullon F, Perez Balini N, Paviotti C, Liprandi MI, Palacios IF.
Argentine randomized trial of percutaneous transluminal coronary angio-
plasty versus coronary artery bypass surgery in multivessel disease
(ERACI). J Am Coll Cardiol 1993;22:1060—7.
[4] Hamm C, Reimers J, Ischinger T, Rupprecht HJ, Berger J, Bleifeld W. A
randomized study of coronary angioplasty compared with bypass surgery
in patients with symptomatic multivessel coronary disease (GABI trial). N
Engl J Med 1994;331:1037—43.
[5] King S, Lembo N, Weintraub WAS, Barnhart HX, Kutner MH, Alazraki NP,
Guyton RA, Zhao XQ. A randomized trial comparing coronary angioplasty
with coronary by pass surgery (EAST trial). N Engl J Med 1994;331:1044—
50.
[6] Coronary angioplasty versus coronary artery bypass surgery: the rando-
mized intervention treatment angina trial (RITA). Lancet 1993;341:
573—80.
[7] The Bypass Angioplasty Revascularization Investigation (BARI) investiga-
tors. Comparison of coronary bypass surgery with angioplasty in patients
with multivessel disease. N Engl J Med 1996;335:217—25.
[8] First year results of CABRI (coronary angioplasty versus bypass revascu-
larization investigation). Lancet 1995;346:1179—84.
[9] Kurbaan AS, Timothy J, Ilsley CD, Sigwart U, Rickards AF, On behalf of the
CABRI Investigators (Coronary Angioplasty versus Bypass Revasculariza-
tion Investigation). Difference in the mortality of the CABRI diabetic and
nondiabetic population and its relation to coronary artery disease and the
revascularization mode. Am J Cardiol 2001;87:947—50.
[10] Buda AJ, MacDonalds II, Anderson MJ, Strauss HD, David TE, Berman ND.
Long term results following coronary bypass operation: importance of
preoperative factors and complete revascularization. J Thorac Surg
1981;82:383—90.
[11] Cosgrove DM, Loop FD, Lytle BW, Gill CC, Golding LA, Gibson C, Stewart
RW, Taylor PC, Goormastic M. Determinants of 10 year survival after
primary myocardial revascularization. Ann Surg 1985;202:480—90.
[12] Bourassa MG, Yeh W, Holubkov R, Sopko G, Detre KM. Long term outcome
of patients with incomplete vs complete revascularization after multi-
vessel PTCA. Eur Heart J 1998;19:103—11.
[13] Van Der Brand MJ, Rensing BJ, Morel MA, Foley DP, de Valk V, Breeman A,
Suryapranata H, Haalebos MM, Wijns W, Wellens F, Balcon R, Magee P,
Ribeiro E, Buffolo E, Unger F, Serruys PW. The effect of completeness of
revascularization on event free survival at one year in the ARTS trial. J Am
Coll Cardiol 2002;19:559—64.
[14] Hannan EL, Racz M, Holmes DR, King 3rd SB, Walford G, Ambrose JA,
Sharma S, Katz S, Clark LT, Jones RH. Impact of completeness of percu-
taneous coronary intervention revascularization on long term outcomes
in the stent era. Circulation 2006;113:2406—12.
[15] Ivanhoe RJ, Weintraub WS, Douglas Jr JS, Lembo NJ, Furman M, Gershony
G, Cohen CL, King 3rd SB. Percutaneous transluminal coronary angio-
plasty of chronic total occlusion. Primary success, restenosis and long
term clinical follow up. Circulation 1992;85:106—15.
[16] Suero JA, Marso SP, Jones PG, Laster SB, Huber KC, Giorgi LV, Johnson WL,
Rutherford BD. Procedural outcomes and long term survival among
patients undergoing percutaneous coronary intervention of a chronic
total occlusion in native coronary arteries: a 20 years experience. J
Am Coll Cardiol 2001;38:409—14.
[17] Olivari Z, Rubartelli P, Piscione F, Ettori F, Fontanelli A, Salemme L,
Giachero C, Di Mario C, Gabrielli G, Spedicato L, Bedogni F, TOAST-GISE
Investigators. Immediate results and one year clinical outcome after
percutaneous coronary interventions in chronic total occlusions. Data
from the TOAST-GISE study. J Am Coll Cardiol 2003;41:1672—8.
[18] Puma JA, Sketch Jr MH, Tcheng JE, Gardner LH, Nelson CL, Phillips HR,
Stack RS, Califf RM. The natural history of single vessel chronic coronary
occlusion: a 25 year experience. Am Heart J 1997;133:393—9.
[19] Kiemeneij F, Serruys PW, Macaya C, Rutsch W, Heyndrickx G, Albertsson P,
Fajadet J, Legrand V, Materne P, Belardi J, Sigwart U, Colombo A, Goy JJ,
Disco CM, Morel MA. Continued benefit of coronary stenting versus balloon
angioplasty: five year follow up of Benestent-I. J Am Coll Cardiol
2001;37:1598—603.
[20] Babapulle MN. A hierarchical Bayesan meta-analysis of randomized
clinical trials of drug eluting stents. J Am Coll Cardiol 2001;37:1598—
603.
E. Martuscelli et al. / European Journal of Cardio-thoracic Surgery 33 (2008) 4—8
8
