Is Complete Revascularisation Mandated for all Patients with Multivessel Coronary Artery Disease?

Abstract

CoronaryMultivessel coronary artery disease (MVCAD) is defined by the presence of ≥50 % diameter stenosis of two or more epicardial coronary arteries.The presence of MVCAD indicates poorer prognosis and a significantly higher mortality than single-vessel disease. In MVCAD, revascularisation can be achieved by either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG).1,2 A comprehensive definition of the adequacy of myocardial revascularisation should take into account the size of the vessel, the angiographic and functional severity of the lesion, and the viability of the myocardial territory. 3 Accordingly, anatomic and functional complete revascularisation (CR) are not always synonymous. Generally, the anatomic CR is defined by treatment of all ≥50 % stenosis in vessels of ≥1.5 mm diameter, whereas functional CR is defined by treatment of all lesions assessed as functionally relevant (with both invasive or non-invasive methods) in the presence of myocardial viability in the dependent territory, see Table 1. 3At present, only a few trials have been specifically designed to directly evaluate the adequacy of revascularisation. Current literature, mostly relying on meta-analyses of non-randomised observational studies, 4,5 lists the adequacy of revascularisation among factors that should guide the choice of treatment strategy. In most patients with MVCAD, the main advantage of CABG over PCI seems to be conferred by the achievement of more extensive revascularisation. Most of the difference in terms of the benefit of CABG over PCI seems to derive from patients who undergo incomplete revascularisation (IR). As documented in a recent patient-level analysis, long-term mortality was similar between patients undergoing CR with either PCI or CABG, whereas it was significantly higher with IR after PCI than CABG. 6Although much less invasive than traditional CABG, PCI yields lower rates of CR in patients with multiple coronary lesions. 7 IR can occasionally be implemented in addition to CABG in order to reduce complications, mainly when minimally invasive or off-pump surgery is attempted. AbstractIn multivessel coronary artery disease (MVCAD), myocardial revascularisation can be achieved by percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), with complete revascularisation on all diseased coronary segments or with incomplete revascularisation on selectively targeted lesions. Complete revascularisation confers a long-term prognostic benefit, but is associated with a higher rate of periprocedural events compared with incomplete revascularisation. In most patients with MVCAD, the main advantage of CABG over PCI is conferred by the achievement of more extensive revascularisation. According to current international guidelines, PCI is generally preferred in single-vessel disease, low-risk MVCAD or isolated left main disease; whereas CABG is usually recommended in patients with complex two-vessel disease, most patients with three-vessel disease and/or non-isolate...

Challenging two-staged percutaneous coronary intervention in multivessel coronary artery disease with a high SYNTAX score: feasible, yet complicated

“…Two EES (3.5 × 38 mm; 4.0 × 38 mm) were implanted into the RCA via the right radial artery access (Figure 1 D). The anginal symptoms alleviated and the further course was uneventful, confirming the completeness of revascularization by clinical judgement [2]. Control echocardiography showed no new wall motion abnormalities and normal left ventricle ejection fraction.…”

Evaluation of Oxidative Status in Elderly Patients with Multiple Cerebral Infarctions and Multiple Chronic Total Coronary Occlusions

“…The numbers of patients with MCI+OVCL, MCI+TVCL, and MCI+MVCL were 230, 222, and 213, respectively. The patients with MCI+chronic total coronary occlusions defined as 100% obstruction of a coronary artery [12] were included in MCI +one-vessel coronary occlusion (OVCO) group (n = 59), MCI+two-vessel coronary occlusion (TVCO) group (n = 57 ), MCI+multiple-vessel coronary occlusion (MVCO) defined as three-vessel coronary occlusions [13]…”

Debate of Percutaneous Coronary Intervention versus Coronary Artery Bypass Grafting in a Multimorbidity Patient with Complex Coronary Lesions

“…Complete revascularization (CR) in patients with multivessel coronary artery disease (CAD) is a crucial prognostic factor that should be taken into consideration in the decision between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG), as it is associated with reduced cardiovascular mortality regardless of the method of implementation [1,2]. Frequently, the best reperfusion strategy has to be considered with prudence, as CABG in patients with comorbidities may be accompanied by an increased risk for adverse outcomes, which is also high when performing PCI in very complex lesions along with a lower success rate in those cases [3,4].…”