1) Complete revascularization (CR), defined as treating all significant coronary stenoses, is associated with lower mortality compared to incomplete revascularization (IR) based on observational studies and randomized trials. IR is more common after percutaneous coronary intervention (PCI) than coronary artery bypass grafting (CABG). 2) For stable coronary artery disease (SCAD), CR is recommended when feasible, while for acute coronary syndromes (ACS) and ST-segment elevation myocardial infarction (STEMI), treating the culprit lesion only is usually recommended initially, with staged revascularization of non-culprit lesions if needed. 3) Randomized trials of preventive PCI of non-culprit lesions in STEMI

1. Revascularizació n completa
o incompleta en enfermedad
coronaria
José Miguel Vegas Valle
Servicio de Cardiología
Hospital de Cabueñes, Gijón
josemivv@secardiologia.es

2. Background

3. • The definition of MVD varies from study to study.
• Depending on wich definition is used the frecuency
varies substantially, as do the outcomes of patients with
MVD.
• The diferent definitions are one of the reason that is
difficult to compare CABG vs PCI in non-randomized
trials.
MULTILESION PCI IS NOT MULTIVESSEL PCI
Heterogeneity of Patients with Multivessel
Disease:
Implication for Revascularisation Strategies
Definition of Multivessel Coronary Artery Disease

4. Heterogeneity of Patients with Multivessel
Disease:
Implication for Revascularisation Strategies
Definition of Multivessel Coronary Artery Disease
Coronary Artery Surgery Study (CASS)
definition of coronary artery disease (CAD):
1-vessel: > 70% stenosis one epicardial vessel
2-vessels: > 70% stenosis two epicardial vessels >
50% stenosis of the left main
3-vessels: > 70% stenosis three epicardial vessels Any of
the above leading to three
William JR et als, Circulation 68, No. 5, 939-950, 1983.

5. Heterogeneity of Patients with Multivessel
Disease:
Implication for Revascularisation Strategies
Multivessel disease and outcome in CAD
Visual coronary artery disease in
angiography is a prognostic marker

6. Heterogeneity of Patients with Multivessel
Disease:
Implication for Revascularisation Strategies
Definition of Multivessel Coronary Artery Disease
Sant’Anna FM et al, AJC: 2007,(99),504

7. Revascularization in
SCAD

8. European Guidelines:
Revascularization in SCAD
2014 ESC/EACTS Guidelines on myocardial revascularization.
European Heart Journal. doi:10.1093/eurheartj/ehu278

9. Revascularization and outcome.SCAD
n engl j med 356;15

10. Revascularization and outcome.
SCAD
• Relevant in the context of the ongoing multicenter ISCHEMIA trial, which studies effects of
revascularization compared with MT in patients with at least moderate ischemia.
• Differs importantly from a recently meta-analysis of PCI versus MT that includes studies
in which ischemia was based on either suggestive symptoms or abnormal electrocardiography (or
routine ETT) without adjunctive documenting ischemia.
RCTs that enrolled patients with objective evidence of myocardial ischemia as
assessed by noninvasive stress imaging or abnormal FFR.
Am J Cardiol 2015;115:1194e1199
JAMA Intern Med 2014;174:232e240

11. Patients with Multivessel Disease and SCAD:
Complete vs incomplete revascularization
• Observational studies and subgroup analysis of randomized clinical
trials (RCT) from 1970 through September 2012
• 89,883 patients, of whom 45,417 (50.5%) received CR and 44,466
(49.5%) received IR
IR was more common after
PCI than after CABG (56% vs.
25%; p < 0.001)
CR was associated with lower
long-term mortality
Mortality benefit associated
with CR was consistent
irrespective of
revascularization modality
J Am Coll Cardiol 2013;62:1421–31

12. NEJM Vol 360, No 3, pp 213-224.
No diferences in basal characteristics
Significant less contrast media, material cost and length hospital
stay in FFR-Guided PCI group
Patients with Multivessel Disease and SCAD:
FAME trialStudy population, basal and angiographyc tools

13. Routine FFR in patients with multivessel CAD undergoing
PCI with drug-eluting stents significantly reduces
mortality and myocardial infarction at 2 years compared
with standard angiography-guided PCI
NEJM Vol 360, No 3, pp 213-224. J Am Coll Cardiol 2010;56:177–84
4,2%
Patients with Multivessel Disease and SCAD:
FAME trialStudy population, basal and angiographyc tools

15. No diferences in death or MI
Repeat revascularization: CABG 5,9% vs PCI 13,7%

16. Patients with Multivessel Disease and
SCAD:
Recommendations according to extent
2014 ESC/EACTS Guidelines on myocardial revascularization.
European Heart Journal. doi:10.1093/eurheartj/ehu278

17. STEMI

18. Heterogeneity of Patients with Multivessel
Disease:
Implication for Revascularisation Strategies
Multivessel disease and outcome in STEMI
30-Day Mortality for Patients With or Without
Non–Infarct-Related Coronary Artery Disease
4.3% vs 1.7%, risk difference, 2.7%[95%
CI, 2.3%to 3.0%] P < .001
68 765 patients enrolled in 8 trials, 28 282 patients with valid
angiographic data.
Defined as stenosis of 50% or more of a major epicardial artery.
52.8% (14 929) had
obstructive non-IRA
disease:
• 29.6%: 1vessel
• 18.8%: 2 vessels
JAMA. 2014;312(19):2019-2027.

19. Heterogeneity of Patients with Multivessel
Disease:
Implication for Revascularisation Strategies
Multivessel disease and outcome in STEMI
Sorajja P et al. Eur Heart J 2007;28:1709-16
CADILLAC trial: 2082 patients with acute myocardial
infarction and primary PCI

20. Patients with Multivessel Disease:
Culprit vs multivessel revascularization
STEMI: ESC Guidelines
2014 ESC/EACTS Guidelines on
myocardial revascularization.
European Heart Journal. 2014.
doi:10.1093/eurheartj/ehu278

21. Patients with Multivessel Disease:
Culprit vs multivessel revascularization
STEMI: Pros & Cons for Preventive PCI
• Non culprit lesion not
associated with
symptoms/ ischemia
• Overestimation of severity
at time of acute angiography
J Am Coll Cardiol Intv 2015;8:131–8)
EuroIntervention 2014;10-T47-T54n engl j med 369;12
• Improve hemodynamics
• Prevent reinfarction
– Vulnerable non-culprit lesion can
become culprit(“pan-coronary
inflammation”)
– STEMI is a pan-coronary
inflammatory disease.

22. Patients with Multivessel Disease:
Culprit vs multivessel revascularization
STEMI
EuroIntervention 2014;10-T47-T54
Advantages (+) and
disadvantages (–) of
different PCI strategies for
non-culprit lesions in
patients with STEMI and
MVD

23. Patients with Multivessel Disease:
Culprit vs multivessel revascularization
STEMI: Variables to choose strategy
EuroIntervention 2014;10-T47-T54

24. Patients with Multivessel Disease:
Culprit vs multivessel revascularization
STEMI: Prior evidence
Four prospective and 14 retrospective studies involving 40,280 patients.
Meta-analysis supports current guidelines discouraging
performance of multivessel primary PCI for STEMI.
When significant nonculprit vessel lesions are suitable for
PCI, they should only be treated during staged
procedure

25. Patients with Multivessel Disease:
Culprit vs multivessel revascularization
STEMI: Prior evidence

26. Patients with Multivessel Disease:
Culprit vs multivessel revascularization
STEMI: Prior evidence

27. Patients with Multivessel Disease:
Culprit vs multivessel revascularization
STEMI: PRAMI Trial
• IRA had been successfully treated
• PCI treatable stenosis of 50% or more in one or more
• Staged PCI in non preventive group without angina was discouraged
(angina driven stage PCI)
465 patients randomly assigned to preventive PCI (234) or no preventive
PCI (231 patients).
N Engl J Med 2013;369:1115-23

28. Patients with Multivessel Disease:
Culprit vs multivessel revascularization
STEMI: PRAMI Trial
N Engl J Med 2013;369:1115-23
• During 5 years recruited 465
patients in 5 centers.
• Low number of events (Cardiac
death: 4/10)
• Demographics
• Angiographic characteristics
unknown
• Non fatal MI due to spontaneous MI
or peri-procedural MI?
• End-point includes refractory angina

29. Patients with Multivessel Disease:
Culprit vs multivessel revascularization
STEMI: CvLPRIT Trial
• Randomized 146 primary PCI patients to treatment of the IRA only and 150
to complete revascularization that treated the culprit vessel plus any other
arteries with >70% stenosis.
• PCI to non-culprit vessel was performed in the same index admission
JACC , 2015-03-17, Volume 65, Issue 10, Pages 963-972

30. Patients with Multivessel Disease:
Culprit vs multivessel revascularization
STEMI: CvLPRIT Trial
• Low number of events (Cardiac death: 2/6)
• End-point includes refractory angina/revascularization and heart failure
• None of the individual endpoints reached statistical significance
JACC , 2015-03-17, Volume 65, Issue 10, Pages 963-972

31. Patients with Multivessel Disease:
Culprit vs multivessel revascularization
STEMI: DANAMI 3-PRIMULTI
627 patients; 313 PCI of the infarct-related artery only and 314
complete revascularisation guided by FFR.
Median follow-up was 27 months.
Two university hospitals in Denmark 2011-2014.

32. Patients with Multivessel Disease:
Culprit vs multivessel revascularization
STEMI: DANAMI 3-PRIMULTI
In patients with STEMI and multivessel disease, complete
revascularisation guided by FFR significantly reduces the risk of
future events compared with no further invasive intervention. This
effect is driven by fewer repeat revascularisations

33. Patients with Multivessel Disease:
Culprit vs multivessel revascularization
STEMI: Real world
Mortality at 30 days (4.2% versus 8.7%; P=0.025), and at 1 year (6.8%
versus 10.2%; P=0.05)
• CVI versus multivessel
intervention
• 3984 patients with multivessel
disease undergoing PPCI
• Between 2004 and 2011
• 8 tertiary cardiac centers
Circ Cardiovas Qual Outcomes. 2014;7:936-943

34. ACS

35. Patients with Multivessel Disease:
Culprit vs multivessel revascularization
Acute Coronary Syndromes
J Am Coll Cardiol 2007;49:849–54
No differences in
death or MI

36. Patients with Multivessel Disease:
Culprit vs multivessel revascularization
Acute Coronary Syndromes
EuroIntervention 2013;9:916-922
Retrospective cohort study of 990 consecutive patients who underwent either
single-vessel PCI (n=379) or multivessel PCI (n=611) in Non-ST ACS

37. Patients with Multivessel Disease:
Culprit vs multivessel revascularization
Acute Coronary Syndromes
• 8 observational studies with 8,425 patients (3,227 multivessel and 5,198
culprit-only PCI)
• Mean follow-up duration was 18 months.
There were no significant differences in all-cause mortality and
myocardial infarction.
Am J Cardiol 2015;115:1027e1032

38. Patients with Multivessel Disease:
Culprit vs multivessel revascularization
Acute Coronary Syndromes: FFR Guided
revascularization
Rev Esp Cardiol. 2012;65(2):164–170
JACC Cardiovasc Interv, 2011 Vol 4, No 11, pp 1183-89.
FAME substudy: 328 patiens
with Non-ST-ACS:
Similar data in outcomes, contrast
media, hospital stay

40. Special Settings

41. Muhlestein J.Am Heart J. 2003;146 Hlatky, The Lancet, Vol 373 April 4, 2009
SPECIAL SETTINGS
Diabetes

42. SPECIAL SETTINGS Chronic total occlusion
Eur Heart J. 2012 Mar;33(6):768-75
HORIZONS AMI Subestudy:
• 3283 patients undergoing primary PCI, 283
(8.6%) had MVD with a CTO.
• MVD with CTO in a non-IRA was an independent
predictor of both 30-day and 3-year mortality.
• During 3-year follow-up, patients with failed
procedure had higher cardiac mortality (22.9%
versus 9.0%, P = 0.020) and lower MACE-free
survival (50.0% versus 72.0%, P = 0.009) compared
to patients with successful procedure.