How DECISION-CTO Can Help Guide the Decision to Perform Chronic Total Occlusion Percutaneous Coronary Intervention
2019; Lippincott Williams & Wilkins; Volume: 139; Issue: 14 Linguagem: Inglês
10.1161/circulationaha.119.039835
ISSN1524-4539
AutoresEmmanouil S. Brilakis, Kambis Mashayekhi, M. Nicholas Burke,
Tópico(s)Acute Myocardial Infarction Research
ResumoHomeCirculationVol. 139, No. 14How DECISION-CTO Can Help Guide the Decision to Perform Chronic Total Occlusion Percutaneous Coronary Intervention Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBHow DECISION-CTO Can Help Guide the Decision to Perform Chronic Total Occlusion Percutaneous Coronary Intervention Emmanouil S. Brilakis, MD, PhD, Kambis Mashayekhi, MD and M. Nicholas Burke, MD Emmanouil S. BrilakisEmmanouil S. Brilakis Emmanouil S. Brilakis, MD, PhD, Minneapolis Heart Institute, 920 E 28th St #300, Minneapolis, MN 55407. Email E-mail Address: [email protected] Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, MN (E.S.B., M.N.B.). , Kambis MashayekhiKambis Mashayekhi Division of Cardiology and Angiology II, University Heart Center Freiburg, Bad Krozingen, Germany (K.M.). and M. Nicholas BurkeM. Nicholas Burke Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, MN (E.S.B., M.N.B.). Originally published1 Apr 2019https://doi.org/10.1161/CIRCULATIONAHA.119.039835Circulation. 2019;139:1684–1687This article is a commentary on the followingRandomized Trial Evaluating Percutaneous Coronary Intervention for the Treatment of Chronic Total OcclusionArticle, see p 1674Coronary chronic total occlusions (CTOs) are completely occluded coronary arteries without antegrade coronary flow and an estimated duration of at least 3 months.1 CTOs are commonly encountered in patients undergoing coronary angiography (in 15%–52%).1–5 Patients with CTOs in the setting of multivessel complex coronary artery disease are often treated with coronary bypass graft surgery. However, some patients with complex coronary artery disease are not candidates for coronary artery bypass grafting (CABG), refuse CABG, or have already undergone CABG. Some other patients have isolated CTOs or few additional lesions. Should such patients undergo CTO percutaneous coronary intervention (PCI)? This can be a challenging decision to make because CTO PCI has lower success and higher complication rates in comparison with PCI of nonocclusive lesions.6,7What is KnownSeveral observational studies and 4 randomized, controlled trials have examined the impact of CTO PCI on clinical outcomes.Earlier studies compared successful versus failed CTO PCI and reported significantly worse early and late outcomes among patients who had failed procedures.8 This comparison is hard to interpret because patients who have failed procedures have worse baseline clinical characteristics, and the failure itself may predispose to subsequent adverse events.8 Observational studies have also compared CTO PCI versus medical therapy and have generally reported better outcomes with CTO PCI, yet the lack of randomization also prevents any definitive conclusions.1Four randomized, controlled clinical trials of CTO PCI versus no CTO PCI have been published to date.The EXPLORE trial (Evaluating Xience and Left Ventricular Function in Percutaneous Coronary Intervention on Occlusions After ST-Elevation Myocardial Infarction) randomly assigned 304 patients who underwent primary PCI for acute ST-segment–elevation acute myocardial infarction and had a coexisting noninfarct-related artery CTO to CTO PCI (73% success) versus no CTO PCI. At 4 months, cardiac MRI showed no difference between the 2 groups in left ventricular ejection fraction and left ventricular end-diastolic volume (the primary end points of the study).9Similarly, the REVASC trial (A Randomized Trial to Assess Regional Left Ventricular Function after Stent Implantation in Chronic Total Occlusion) in patients with a stable coronary artery disease and a CTO randomly assigned 205 patients to CTO PCI and no CTO PCI. At 6 months, cardiac MRI showed no difference between the 2 groups in segmental wall thickening in the CTO territory and regional and global left ventricular function, as well.10The EuroCTO trial (A Randomized Multicentre Trial to Evaluate the Utilization of Revascularization or Optimal Medical Therapy for the Treatment of Chronic Total Coronary Occlusions) randomly assigned 396 (instead of the planned 1200) patients 2:1 to CTO PCI versus no CTO PCI. At 12 months, patients randomly assigned to CTO PCI (86% success) had more improvement in the angina frequency (P=0.003) and quality of life (P=0.007) dimensions of the Seattle Angina Questionnaire with no difference in the incidence of major adverse cardiovascular and cerebrovascular events.11The IMPACTOR-CTO trial (Impact on Inducible Myocardial Ischemia of Percutaneous Coronary Intervention versus Optimal Medical Therapy in Patients with Right Coronary Artery Chronic Total Occlusion) randomly assigned 94 patients with isolated right coronary artery CTO to CTO PCI or no CTO PCI at a single Russian center. CTO PCI was associated with greater reduction in ischemia and improvement in 6-minute walk distance and quality of life as assessed by the SF-36 health survey.12Decision-CTOIn this issue of Circulation, the results of the DECISION-CTO trial (Drug-Eluting Stent Implantation versus Optimal Medical Treatment in Patients with ChronIc Total Occlusion) are reported.13 DECISION-CTO is the largest randomized-controlled trial of CTO PCI performed to date with 834 patients randomly assigned,13 which was fewer than originally planned (the study was stopped early because of difficulties with enrollment), but nevertheless a tremendous achievement given challenges associated with randomly assigning patients with CTO. The investigative team should be congratulated for this accomplishment. Patients with coronary CTOs were randomly assigned to CTO PCI versus no CTO PCI, and CTO PCI had a high success rate (91%). During a median follow-up of 4.0 years, the incidence of the composite of death, myocardial infarction, stroke, and target vessel revascularization was similar between the 2 study groups.At first glance, the results seem consistent with the results of the COURAGE trial (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation)14 that randomly assigned patients with stable coronary artery to PCI versus no PCI, reporting no differences in the hard clinical end point. DECISION-CTO, unlike COURAGE, did not report improved quality of life in the PCI arm; however, careful examination of the study design and results reveals several limitations that need to be taken into consideration when interpreting the study results:1. The noninferiority design is not suitable when comparing a more costly and potentially risky intervention with medical treatment alone. A superiority design and power calculation should have been used.2. In contrast to EuroCTO, which enrolled patients after revascularization of non-CTO lesions, many patients in DECISION-CTO had multivessel coronary artery disease at the time of enrollment, and many of them in both groups underwent revascularization of non-CTO lesions. It is unknown whether the patients remained symptomatic after revascularization of those non-CTO lesions.3. The study was underpowered because of the early termination of enrollment (64% post hoc power).4. Nearly 1 of 5 patients randomly assigned to no CTO PCI crossed over to CTO PCI within 3 days of randomization, which further limits the ability of the study to determine differences between the study groups.5. The patients' baseline symptoms were mild or absent (14% of patients presented with silent ischemia).When Should CTO PCI be Performed?CTO PCI should be performed when the anticipated benefits exceed the potential risks (Figure).1 At present, the main benefit and key indication remains symptom improvement (ie, improvement in angina or dyspnea, which is often an angina equivalent in these patients). Realizing the benefits requires successful CTO recanalization, the likelihood of which depends on the angiographic characteristics of the occlusion and the experience of the operator.Download figureDownload PowerPointFigure. Overview of the potential risks and benefits of CTO PCI. CTO indicates chronic total occlusion; DAPT, dual antiplatelet therapy; PCI, percutaneous coronary intervention; and PROGRESS- CTO, Prospective Global Registry for the Study of Chronic Total Occlusion Intervention.15,16 Reproduced from Brilakis17 with permission. Copyright © 2017, Elsevier.Given its important limitations, DECISION-CTO does not negate the results of the EuroCTO trial,11 and symptom improvement remains the main indication for CTO PCI. DECISION-CTO cannot and does not answer the question of whether CTO PCI can affect hard clinical outcomes. A much larger study, potentially enrolling patients with CTOs causing a large ischemic burden, would be required to prove or disprove this concept. The ongoing NOBLE-CTO trial (Nordic-Baltic Randomized Registry Study for Evaluation of PCI in Chronic Total Coronary Occlusion; NCT03392415) and ISCHEMIA-CTO trial (Nordic and Spanish Randomized Trial on the Effect of Revascularization or Optimal Medical Therapy of Chronic Total Coronary Occlusions With Myocardial Ischemia; NCT03563417) will help answer this question, but are estimated to be completed in 2037 and 2028, respectively.CTO PCI carries risk for complications, such as perforation, myocardial infarction, emergency CABG, radiation skin injury, or even death. This risk is ≈3% at experienced centers and should be discussed with the patient along with the potential benefits and anticipated success rates (85%–90% at experienced centers)1,4,5,7,18 to make the best possible decision.Similar to CABG, CTO PCI is a powerful tool for achieving coronary revascularization. Judicious selection of patients who can benefit from the procedure (Figure) and thoughtful performance of the procedure by experienced operators can lead to optimal outcomes.DisclosuresDr Brilakis reports consulting/speaker honoraria from Abbott Vascular, American Heart Association (associate editor Circulation), Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), CSI, Elsevier, GE Healthcare, InfraRedx, and Medtronic; reports research support from Regeneron and Siemens; is a shareholder in MHI Ventures; and is on the Board of Trustees for the Society of Cardiovascular Angiography and Interventions. Dr Mashayekhi reports consulting/speaker/proctoring honoraria from Abbott Vascular, Ashai Intecc, AstraZeneca, Biotronik, Boston Scientific, Cardinal Health, Daiichi Sankyo, Medtronic, Teleflex, and Terumo. Dr Burke reports consulting and speaking honoraria from Abbott Vascular and Boston Scientific.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.https://www.ahajournals.org/journal/circEmmanouil S. Brilakis, MD, PhD, Minneapolis Heart Institute, 920 E 28th St #300, Minneapolis, MN 55407. Email [email protected]comReferences1. Tajti P, Burke MN, Karmpaliotis D, Alaswad K, Werner GS, Azzalini L, Carlino M, Patel M, Mashayekhi K, Egred M, Krestyaninov O, Khelimskii D, Nicholson WJ, Ungi I, Galassi AR, Banerjee S, Brilakis ES. Update in the percutaneous management of coronary chronic total occlusions.JACC Cardiovasc Interv. 2018; 11:615–625. doi: 10.1016/j.jcin.2017.10.052CrossrefMedlineGoogle Scholar2. Fefer P, Knudtson ML, Cheema AN, Galbraith PD, Osherov AB, Yalonetsky S, Gannot S, Samuel M, Weisbrod M, Bierstone D, Sparkes JD, Wright GA, Strauss BH. Current perspectives on coronary chronic total occlusions: the Canadian Multicenter Chronic Total Occlusions Registry.J Am Coll Cardiol. 2012; 59:991–997. doi: 10.1016/j.jacc.2011.12.007CrossrefMedlineGoogle Scholar3. Jeroudi OM, Alomar ME, Michael TT, El Sabbagh A, Patel VG, Mogabgab O, Fuh E, Sherbet D, Lo N, Roesle M, Rangan BV, Abdullah SM, Hastings JL, Grodin J, Banerjee S, Brilakis ES. Prevalence and management of coronary chronic total occlusions in a tertiary Veterans Affairs hospital.Catheter Cardiovasc Interv. 2014; 84:637–643. doi: 10.1002/ccd.25264CrossrefMedlineGoogle Scholar4. Habara M, Tsuchikane E, Muramatsu T, Kashima Y, Okamura A, Mutoh M, Yamane M, Oida A, Oikawa Y, Hasegawa K; Retrograde Summit Investigators. Comparison of percutaneous coronary intervention for chronic total occlusion outcome according to operator experience from the Japanese retrograde summit registry.Catheter Cardiovasc Interv. 2016; 87:1027–1035. doi: 10.1002/ccd.26354CrossrefMedlineGoogle Scholar5. Konstantinidis NV, Werner GS, Deftereos S, Di Mario C, Galassi AR, Buettner JH, Avran A, Reifart N, Goktekin O, Garbo R, Bufe A, Mashayekhi K, Boudou N, Meyer-Geßner M, Lauer B, Elhadad S, Christiansen EH, Escaned J, Hildick-Smith D, Carlino M, Louvard Y, Lefèvre T, Angelis L, Giannopoulos G, Sianos G; Euro CTO Club. Temporal trends in chronic total occlusion interventions in Europe.Circ Cardiovasc Interv. 2018; 11:e006229. doi: 10.1161/CIRCINTERVENTIONS.117.006229LinkGoogle Scholar6. Brilakis ES, Banerjee S, Karmpaliotis D, Lombardi WL, Tsai TT, Shunk KA, Kennedy KF, Spertus JA, Holmes DR, Grantham JA. Procedural outcomes of chronic total occlusion percutaneous coronary intervention: a report from the NCDR (National Cardiovascular Data Registry).JACC Cardiovasc Interv. 2015; 8:245–253. doi: 10.1016/j.jcin.2014.08.014CrossrefMedlineGoogle Scholar7. Sapontis J, Salisbury AC, Yeh RW, Cohen DJ, Hirai T, Lombardi W, McCabe JM, Karmpaliotis D, Moses J, Nicholson WJ, Pershad A, Wyman RM, Spaedy A, Cook S, Doshi P, Federici R, Thompson CR, Marso SP, Nugent K, Gosch K, Spertus JA, Grantham JA. Early procedural and health status outcomes after chronic total occlusion angioplasty: a report from the OPEN-CTO Registry (Outcomes, Patient Health Status, and Efficiency in Chronic Total Occlusion Hybrid Procedures).JACC Cardiovasc Interv. 2017; 10:1523–1534. doi: 10.1016/j.jcin.2017.05.065CrossrefMedlineGoogle Scholar8. Christakopoulos GE, Christopoulos G, Carlino M, Jeroudi OM, Roesle M, Rangan BV, Abdullah S, Grodin J, Kumbhani DJ, Vo M, Luna M, Alaswad K, Karmpaliotis D, Rinfret S, Garcia S, Banerjee S, Brilakis ES. Meta-analysis of clinical outcomes of patients who underwent percutaneous coronary interventions for chronic total occlusions.Am J Cardiol. 2015; 115:1367–1375. doi: 10.1016/j.amjcard.2015.02.038CrossrefMedlineGoogle Scholar9. Henriques JP, Hoebers LP, Råmunddal T, Laanmets P, Eriksen E, Bax M, Ioanes D, Suttorp MJ, Strauss BH, Barbato E, Nijveldt R, van Rossum AC, Marques KM, Elias J, van Dongen IM, Claessen BE, Tijssen JG, van der Schaaf RJ; EXPLORE Trial Investigators. Percutaneous intervention for concurrent chronic total occlusions in patients with STEMI: the EXPLORE Trial.J Am Coll Cardiol. 2016; 68:1622–1632. doi: 10.1016/j.jacc.2016.07.744CrossrefMedlineGoogle Scholar10. Mashayekhi K, Nührenberg TG, Toma A, Gick M, Ferenc M, Hochholzer W, Comberg T, Rothe J, Valina CM, Löffelhardt N, Ayoub M, Zhao M, Bremicker J, Jander N, Minners J, Ruile P, Behnes M, Akin I, Schäufele T, Neumann FJ, Büttner HJ. A randomized trial to assess regional left ventricular function after stent implantation in chronic total occlusion: the REVASC Trial.JACC Cardiovasc Interv. 2018; 11:1982–1991. doi: 10.1016/j.jcin.2018.05.041CrossrefMedlineGoogle Scholar11. Werner GS, Martin-Yuste V, Hildick-Smith D, Boudou N, Sianos G, Gelev V, Rumoroso JR, Erglis A, Christiansen EH, Escaned J, di Mario C, Hovasse T, Teruel L, Bufe A, Lauer B, Bogaerts K, Goicolea J, Spratt JC, Gershlick AH, Galassi AR, Louvard Y; EUROCTO trial investigators. A randomized multicentre trial to compare revascularization with optimal medical therapy for the treatment of chronic total coronary occlusions.Eur Heart J. 2018; 39:2484–2493. doi: 10.1093/eurheartj/ehy220CrossrefMedlineGoogle Scholar12. Obedinskiy AA, Kretov EI, Boukhris M, Kurbatov VP, Osiev AG, Ibn Elhadj Z, Obedinskaya NR, Kasbaoui S, Grazhdankin IO, Prokhorikhin AA, Zubarev DD, Biryukov A, Pokushalov E, Galassi AR, Baystrukov VI. The IMPACTOR-CTO Trial.JACC Cardiovasc Interv. 2018; 11:1309–1311. doi: 10.1016/j.jcin.2018.04.017CrossrefMedlineGoogle Scholar13. Lee SW, Lee PH, Ahn JM, Park DW, Yun SC, Han S, Kang H, Kang SJ, Kim YH, Lee CW, Park SW, Hur SH, Rha SW, Her SH, Choi SW, Lee BK, Lee NH, Lee JY, Cheong SS, Kim MH, Ahn YK, Lim SW, Lee SG, Hiremath S, Santoso T, Udayachalerm W, Cheng JJ, Cohen DJ, Muramatsu T, Tsuchikane E, Asakura Y, Park SJ. Randomized trial evaluating percutaneous coronary intervention for the treatment of chronic total occlusion: the DECISION-CTO trial.Circulation. 2019; 139:1674–1683. doi: 10.1161/CIRCULATIONAHA.118.031313LinkGoogle Scholar14. Boden WE, O'Rourke RA, Teo KK, Hartigan PM, Maron DJ, Kostuk WJ, Knudtson M, Dada M, Casperson P, Harris CL, Chaitman BR, Shaw L, Gosselin G, Nawaz S, Title LM, Gau G, Blaustein AS, Booth DC, Bates ER, Spertus JA, Berman DS, Mancini GB, Weintraub WS; COURAGE Trial Research Group. Optimal medical therapy with or without PCI for stable coronary disease.N Engl J Med. 2007; 356:1503–1516. doi: 10.1056/NEJMoa070829CrossrefMedlineGoogle Scholar15. Christopoulos G, Kandzari DE, Yeh RW, Jaffer FA, Karmpaliotis D, Wyman MR, Alaswad K, Lombardi W, Grantham JA, Moses J, Christakopoulos G, Tarar MN, Rangan BV, Lembo N, Garcia S, Cipher D, Thompson CA, Banerjee S and Brilakis ES. Development and validation of a novel scoring system for predicting technical success of chronic total occlusion percutaneous coronary interventions: the PROGRESS CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention) Score. JACC Cardiovasc Interv. 2016; 9:1–9. doi: 10.1016/j.jcin.2015.09.022CrossrefMedlineGoogle Scholar16. Danek BA, Karatasakis A, Karmpaliotis D, Alaswad K, Yeh RW, Jaffer FA, Patel MP, Mahmud E, Lombardi WL, Wyman MR, Grantham JA, Doing A, Kandzari DE, Lembo NJ, Garcia S, Toma C, Moses JW, Kirtane AJ, Parikh MA, Ali ZA, Karacsonyi J, Rangan BV, Thompson CA, Banerjee S and Brilakis ES. Development and validation of a scoring system for predicting periprocedural complications during percutaneous coronary interventions of chronic total occlusions:the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS CTO) Complications Score.J Am Heart Assoc. 2016; 5:e004272. doi: 10.1161/JAHA.116.004272LinkGoogle Scholar17. Brilakis ES. Manual of Coronary Chronic Total Occlusion Interventions. A Step-By-Step Approach. 2nd ed. Elsevier; 2017.Google Scholar18. Tajti P, Karmpaliotis D, Alaswad K, Jaffer FA, Yeh RW, Patel M, Mahmud E, Choi JW, Burke MN, Doing AH, Dattilo P, Toma C, Smith AJC, Uretsky B, Holper E, Wyman RM, Kandzari DE, Garcia S, Krestyaninov O, Khelimskii D, Koutouzis M, Tsiafoutis I, Moses JW, Lembo NJ, Parikh M, Kirtane AJ, Ali ZA, Doshi D, Rangan BV, Ungi I, Banerjee S, Brilakis ES. The hybrid approach to chronic total occlusion percutaneous coronary intervention: update from the PROGRESS CTO Registry.JACC Cardiovasc Interv. 2018; 11:1325–1335. doi: 10.1016/j.jcin.2018.02.036CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Vanneman M (2022) Anesthetic Considerations for Percutaneous Coronary Intervention for Chronic Total Occlusions—A Narrative Review, Journal of Cardiothoracic and Vascular Anesthesia, 10.1053/j.jvca.2021.08.001, 36:7, (2132-2142), Online publication date: 1-Jul-2022. Shi Y, He S, Luo J, Jian W, Shen X and Liu J (2022) Lesion characteristics and procedural complications of chronic total occlusion percutaneous coronary intervention in patients with prior bypass surgery: A meta‐analysis, Clinical Cardiology, 10.1002/clc.23766, 45:1, (18-30), Online publication date: 1-Jan-2022. Park T, Lee S, Choi K, Lee J, Yang J, Song Y, Hahn J, Choi J, Gwon H, Lee S and Choi S (2021) Late Survival Benefit of Percutaneous Coronary Intervention Compared With Medical Therapy in Patients With Coronary Chronic Total Occlusion: A 10‐Year Follow‐Up Study, Journal of the American Heart Association, 10:6, Online publication date: 16-Mar-2021. Rinfret S and Sandesara P (2021) Reducing Ischemia With CTO PCI, JACC: Cardiovascular Interventions, 10.1016/j.jcin.2021.05.028, 14:13, (1419-1422), Online publication date: 1-Jul-2021. Van den Eynde J, Bennett J, McCutcheon K, Adriaenssens T, Desmet W, Dubois C, Sinnaeve P, Verbelen T, Jacobs S and Oosterlinck W (2021) Heart team 2.0: A decision tree for minimally invasive and hybrid myocardial revascularization, Trends in Cardiovascular Medicine, 10.1016/j.tcm.2020.07.005, 31:6, (382-391), Online publication date: 1-Aug-2021. Mashayekhi K, Bufe A, Werner G, Werner N, Meyer-Gessner M, Liebetrau C, Zahn R, Levenson B, Möllmann H, Nef H and Behnes M (2021) Behandlung von chronischen Koronarverschlüssen (CTO) – Positionspapier der Deutschen Gesellschaft für KardiologieTreatment of chronic coronary artery occlusion (CTO)—Position paper of the German Cardiac Society, Der Kardiologe, 10.1007/s12181-021-00486-5, 15:4, (320-340), Online publication date: 1-Aug-2021. Štípal R, Poloczek M, Sůva M and Kala P (2021) Percutaneous coronary intervention of chronic total occlusion - to whom, when and why, Vnitřní lékařství, 10.36290/vnl.2021.064, 67:4, (E17-E25), Online publication date: 29-Jun-2021. Roth C, Goliasch G, Aschauer S, Gangl C, Ayoub M, Distelmaier K, Frey B, Lang I, Berger R, Mashayekhi K, Ferenc M, Hengstenberg C and Toma A (2020) Impact of treatment strategies on long-term outcome of CTO patients, European Journal of Internal Medicine, 10.1016/j.ejim.2020.03.008, 77, (97-104), Online publication date: 1-Jul-2020. Ybarra L and Rinfret S (2020) Why and How Should We Treat Chronic Total Occlusion? Evolution of State-of-the-Art Methods and Future Directions, Canadian Journal of Cardiology, 10.1016/j.cjca.2020.10.005, Online publication date: 1-Oct-2020. Rahman M, de Winter R, Nap A and Knaapen P (2021) Advances in the Post-coronary Artery Bypass Graft Management of Occlusive Coronary Artery Disease, Interventional Cardiology: Reviews, Research, Resources, 10.15420/icr.2021.12, 16 Rakhimov K and Gori T (2020) Non-pharmacological Treatment of Refractory Angina and Microvascular Angina, Biomedicines, 10.3390/biomedicines8080285, 8:8, (285) Related articlesRandomized Trial Evaluating Percutaneous Coronary Intervention for the Treatment of Chronic Total OcclusionSeung-Whan Lee, et al. Circulation. 2019;139:1674-1683 April 2, 2019Vol 139, Issue 14 Advertisement Article InformationMetrics © 2019 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.119.039835PMID: 30933615 Originally publishedApril 1, 2019 KeywordsEditorialscoronary artery bypasspercutaneous coronary interventioncoronary angiographycoronary occlusionPDF download Advertisement SubjectsPercutaneous Coronary InterventionRevascularizationStent
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