REPEAT INTERVENTIONS AS A LONG-TERM TREATMENT STRATEGY IN THE MANAGEMENT OF PROGRESSIVE CORONARY-ARTERY DISEASE

Objectives. This study investigates whether repeat coronary interventi ons, applied over an extended time period, can successfully curtail th e progression of ischemic symptoms and angiographic lumen narrowing. B ackground. Coronary artery disease is a chronic and generally progress ive disorder, and potential treatment strategies should be examined an d compared with this chronicity in mind. Percutaneous interventional r evascularization procedures could theoretically be useful in controlli ng progression of the disease through repeated use as new coronary les ions arise. However, the outcome of this long-term management concept has not previously been subjected to detailed investigation. Methods. From a consecutive series of 4,357 interventional cardiac procedures, 544 patients were identified who received two or more interventions du ring the 13-year study period. These patients were categorized into on e of three groups: restenosis (repeat interventions limited to the sam e target segment, n = 261), new stenosis (all repeat interventions dir ected to stenoses not previously treated, n = 155) or both (repeat int erventions directed both to the same and to different target lesions, n = 128). Results. Two to five procedures were performed per patient; the time period (mean +/- SD) separating each procedure was significan tly less (p < 0.0001) for the restenosis group (4.2 +/- 2.3 months) th an for the new stenosis (24.2 +/- 23.5 months) or the ''both'' groups (11.4 +/- 11.0 months). Despite the need for repeat procedures, the se verity of angina (mean New York Heart Association functional class 1.6 +/- 0.9) after 6.2 +/- 2.3 years of follow-up was substantially bette r than before the initial procedure (mean functional class 3.2 +/- 0.8 ), with a similar magnitude of change found in all three groups. This long-term functional improvement was mirrored by a corresponding anato mic improvement, with the mean number of diseased vessels remaining co nstant at the time of each procedure (1.5 t 0.7, 1.5 +/- 0.7 and 1.6 /- 0.7, respectively, for the first, second and third procedures, p = NS). The restenosis and the new stenosis groups also demonstrated stat istically similar annual rates of mortality (1.9% vs. 1.8%) and corona ry surgery (2.3% vs. 2.6%), although the restenosis group had a lower rate of infarction (1.4% vs. 3.2%, p = 0.002). Conclusions. Repeat int erventional treatment of newly acquired stenoses provides a rational a pproach for the long-term management of chronic coronary artery diseas e. In addition to yielding a favorable late outcome, the use of this s trategy can result in sustained functional improvement and can check t he progression of clinically significant stenoses.