FFRCT-guided revascularization of silent coronary ischemia compared to best medical therapy following lower-extremity revascularization

Author(s): Gustavs Latkovskis, Edgars Zellans, Agate Krievina, Indulis Kumsars, Sanda Jegere, Andrejs Erglis, Christopher Zarins, Dainis Krievins

Objectives: The aim of this study was to determine whether selective coronary revascularization of Peripheral Artery Disease (PAD) patients with silent coronary ischemia can improve survival following lower-extremity revascularization compared to patients with no cardiac symptoms receiving best medical therapy alone.

Methods: Matched cohort analysis of PAD patients with no cardiac history or symptoms with (a) pre-operative CT-derived fractional flow reserve (FFRCT) evaluation to detect silent coronary ischemia and selective post-operative coronary revascularization (FFRCT-Guided) or (b) standard pre-operative cardiac evaluation with monitored post-operative medical therapy in the VOYAGER PAD trial (Medical Therapy). The status of silent ischemia in Medical Therapy was unknown. Study endpoints included death, Myocardial Infarction (MI) and death or MI.

Results: Among 78 FFRCT-Guided patients, 53 (68%) had silent coronary ischemia (FFRCT ≤ 0.80) of which 29 (55%) had post-operative coronary revascularization. Among 79 Medical Therapy patients none had elective coronary revascularization. During a median follow-up of 30 months, compared to Medical Therapy, FFRCT-Guided patients had fewer deaths (5.1% vs. 22.8%; adjusted Hazard Ratio (HR): 0.292; 95% Confidence Interval (CI) 0.086-0.997; p=0.049), fewer MIs (3.8% vs. 15.2%; HR: 0.233; 95% CI 0.058-0.936; p=0.040) and fewer deaths or MI (7.7% vs. 26.6%, HR 0.323, 95% CI 0.115-0.909, p=0.032).

Conclusion: Coronary revascularization of PAD patients with silent ischemia in addition to medical therapy was associated with fewer deaths and MIs following lower-extremity revascularization compared to PAD patients with no coronary symptoms receiving best medical therapy alone.