multivessel pci on top of culprit lesion revascularization? no way!
TRANSCRIPT
Multivessel PCI on top of culprit Multivessel PCI on top of culprit
lesion revascularization?lesion revascularization?
No way!No way!
Major issues
• How do you define complete
revascularization in multivessel disease
(MVD)?
• What is the risk-benefit balance of culprit
vs multivessel PCI in stable MVD?
• What is the risk-benefit balance of culprit
vs multivessel PCI in acute MVD?
Let us begin with an example Let us begin with an example
from a related field…from a related field…
Is it safer to target one only?
Is it safer to target one only?
Or all of them at once?
Major issues
• How do you define complete
revascularization in multivessel disease
(MVD)?
• What is the risk-benefit balance of culprit
vs multivessel PCI in stable MVD?
• What is the risk-benefit balance of culprit
vs multivessel PCI in acute MVD?
Defining revascularization
• Anatomically complete: PCI of every occluded or
stenotic epicardial vessel
• Functionally complete: PCI of every occluded or
stenotic epicardial vessel of adequate size and supplying
a zone of viable myocardium
• Incomplete (culprit only): PCI of occluded or stenotic
epicardial vessel identified by clinical judgement as
responsible for signs/symptoms of ischemia
• Incomplete (truly): everything else
Hazards of multivessel stenting
Hazards of multivessel stenting
Hazards of multivessel stenting
Orlic et al, JACC 2004
Major issues
• How do you define complete
revascularization in multivessel disease
(MVD)?
• What is the risk-benefit balance of culprit
vs multivessel PCI in stable MVD?
• What is the risk-benefit balance of culprit
vs multivessel PCI in acute MVD?
PCI based only on oculostenotic reflex is not justified in stable MVD
Boden et al, NEJM 2007
Boden et al, NEJM 2007
Boden et al, NEJM 2007
Boden et al, NEJM 2007
Even symptomatic benefits are only marginal in unselected patients
Boden et al, NEJM 2007
Would you trust an hazard ratio of 1.15?
Major issues
• How do you define complete
revascularization in multivessel disease
(MVD)?
• What is the risk-benefit balance of culprit
vs multivessel PCI in stable MVD?
• What is the risk-benefit balance of culprit
vs multivessel PCI in acute MVD?
PCI based only on oculostenotic reflex is also not justified in acute MVD
Hirsch et al, Lancet 2007
Hirsch et al, Lancet 2007
Hirsch et al, Lancet 2007
Hirsch et al, Lancet 2007
Hirsch et al, Lancet 2007
Multivessel PCI in acute MVD: incremental benefits or costs?
Brener et al, Am J Cardiol 2002
Brener et al, Am J Cardiol
2002
Brener et al, Am J Cardiol
2002
What about complete PCI in STEMI?
Single vs multivessel treatment during primary
angioplasty: results of the multicentre
randomised HEpacoat for cuLPrit or
multivessel stenting for Acute Myocardial
Infarction (HELP AMI) Study.
Di Mario C, Mara S, Flavio A, Imad S, Antonio M, Anna P, Emanuela P, Stefano DS,
Angelo R, Stefania C, Anna F, Carmelo C, Antonio C, Monzini N, Bonardi MA.
Int J Cardiovasc Intervent. 2004;6(3-4):128-33.
0
10
20
30
40
50
60
70
Length ofprocedure
In-hospitalMACE
12-monthrePCI
12-monthcosts
Complete PCI group Culprit PCI group
53 vs 69 minutes, p<0.05
0 vs 4%, p=NS
35% vs 17% p=NS
22,330€ vs 20,382€,
p=NS
Di Mario et al, Int J Cardiovasc Intervent 2004
Take home messages
• Current data disCOURAGE from extensive multivessel PCI based only on angiographic assessment in stable MVD
• No definite benefits have been shown from multivessel PCI in patients with acute CAD and MVD (either STEMI or NSTEACS)
• According to evidence available to date, PCI of non-culprit vessels can thus be recommended only is selected cases
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