Staging of multivessel percutaneous coronary interventions: An expert consensus statement from the Society for Cardiovascular Angiography and Interventions

Abstract

Percutaneous coronary interventions (PCIs) to treat multivessel coronary artery disease (MVCAD) may involve single-vessel or multivessel interventions, performed in one or more stages. This consensus statement reviews factors that may influence choice of strategy and includes six recommendations to guide decisions regarding staging of PCI [1]. Every patient who undergoes PCI should receive optimal therapy for coronary disease, ideally before starting the procedure [2]. Multivessel PCI at the time of diagnostic catheterization should be considered only if informed consent included the risks and benefits of multivessel PCI and the risks and benefits of alternative treatments [3]. When considering multivessel PCI, the interventionist should develop a strategy regarding which stenoses to treat or evaluate, and their order, method, and timing. This strategy should maximize patient benefits, minimize patient risk, and consider the factors described in this article [4]. For planned multivessel PCI, additional vessel(s) should be treated only if the first vessel is treated successfully and if anticipated contrast and radiation doses and patient and operator conditions are favorable [5]. After the first stage of the planned multistage PCI, the need for subsequent PCI should be reviewed before it is performed [6]. Third party payers and quality auditors should recognize that multistage PCI for MVCAD is neither an indication of poor quality nor an attempt to increase reimbursement when performed according to recommendations in this article.V C 2011 Wiley Periodicals, Inc.

Staged Versus One-time Complete Revascularization With Percutaneous Coronary Intervention for Multivessel Coronary Artery Disease Patients Without ST-Elevation Myocardial Infarction

“…This is the motivation for the aforementioned bundling experiments of Centers for Medicare and Medicaid Services. 6 According to Blankenship et al, 16 the Medicare physician and hospital payments for single-stage multivessel PCI are $1276 and $15 573, respectively, for in-patient procedures and for staged procedures the respective payments are $1906 and $31 146. Thus, the respective physician and hospital payments are 49% and 100% higher for staged procedures than for single-stage procedures.…”

Painless Myocardial Ischemia Is Associated with Mortality in Patients with Chronic Kidney Disease

“…The last decade has witnessed dramatic changes in how PCI is used in clinical practice [38-41], which is reflected in evolving guidelines [42]. The increasing use of drug-eluting stents as well as refinement in the optimal use of antiplatelet therapy [38-40, 42] mean that the long-term outcomes we report might differ were our study to be conducted today. Indeed, even the selection of appropriate PCI candidates may be changing, with an emerging belief that individuals with single vessel disease outside of the left anterior descending artery may not warrant PCI or even diagnostic catheterization [41].…”

Staged versus One-Time Percutaneous Coronary Intervention Strategy for Multivessel Non-ST Segment Elevation Acute Coronary Syndrome

“…National or private insurance committees in various countries tend to discourage staged procedures, especially if it is associated with readmission and, in real world clinical practice, numerous cardiologists have experienced rejection of reimbursements for the staged procedures in intermediate to very high risk patients with NSTE-ACS. It is obvious that staged procedures are associated with increased medical costs and previous studies reported that the medical cost of staged PCI is twice as expensive as that of onetime PCI 9)10). Therefore, in order to justify the extra medical cost of staged PCI for NSTE-ACS patients with multivessel disease, we need clear and robust evidences that staged PCI is better than one-time PCI in terms of clinical outcomes.…”