By Dmitriy Feldman, MD
Peripheral vascular disease (PVD) and coronary artery disease commonly coexist in patients undergoing PCI. Patients with PVD, even when asymptomatic, are at greater risk of future cardiovascular events as well as mortality. Prior studies, performed primarily in bare metal stent era, demonstrated PVD to be an independent predictor of in-hospital mortality, in-hospital adverse events and even long-term mortality. However, to date, there have been limited outcomes data in PVD patients undergoing PCI in the drug-eluting stent era, where application of more aggressive antiplatelet therapies exists and more advanced stent technology is utilized. The goal of our study was to compare the in-hospital and long-term (4-year) outcomes in patients with and without PVD after undergoing PCI in contemporary interventional practice utilizing DES.
We examined data from a single tertiary care institution from 2004/2005 and evaluated the in-hospital and long-term clinical outcomes in 2,455 patients undergoing nonemergent (urgent or elective) PCI. Of the 2,455 patients, 173 (7%) had PVD and 2,282 (93%) had no reported history of PVD. We included patients only with symptomatic or radiologically documented PVD; therefore, higher risk PVD population was examined. The PVD group had a significantly greater prevalence of diabetes, CHF, prior CVA, prior CABG, chronic renal insufficiency; they were more likely to present with multivessel or left main disease and to undergo an urgent intervention as compared with patients without PVD. The incidence of in-hospital death (1.8% vs. 0.1%, p=0.006) was greater in the PVD group, whereas post-procedural MI and MACE rates including death, stroke, emergent CABG/PCI, were similar in the PVD versus no PVD groups. Long-term 4-year Kaplan-Meier survival (89.2% vs. 76.2%, p<0.001) was significantly higher in patients without PVD compared with PVD patients, respectively. Importantly, after adjustment with a multivariate Cox regression analysis, long-term all-cause survival was similar in patients with versus without PVD (HR 1.16, 95% CI 0.69-1.93, p=0.581).
In contemporary PCI utilizing DES, bivalirudin and clopidogrel, PVD patients continue to have a higher in-hospital and 4-year all-cause mortality. However, in our study this difference in survival was mainly driven by a higher rate of comorbidities in the PVD population undergoing PCI. Therefore, PVD may act as a marker of poor prognosis in this group of patients with severe, diffuse burden of atherosclerosis in multiple vascular beds, and in patients with presence of multiple risk factors that negatively impact long-term survival (e.g. CHF, COPD, diabetes mellitus). This high-risk group of patients with concomitant CAD and PVD deserves very aggressive coronary disease risk factor modification and may benefit from more intensive outpatient monitoring after undergoing PCI in contemporary clinical practice.
Dmitriy N. Feldman, MD is the Director of Endovascular Service, Interventional Cardiac and Endovascular Laboratory, Weill Cornell Medical College/The New York Presbyterian Hospital, New York.