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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