multivessel pci on top of culprit lesion revascularization? no way!
TRANSCRIPT
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Multivessel PCI on top of culprit Multivessel PCI on top of culprit
lesion revascularization?lesion revascularization?
No way!No way!
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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?
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Let us begin with an example Let us begin with an example
from a related field…from a related field…
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Is it safer to target one only?
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Is it safer to target one only?
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Or all of them at once?
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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?
![Page 8: Multivessel PCI on top of culprit lesion revascularization? No way!](https://reader036.vdocument.in/reader036/viewer/2022062518/5697bf8e1a28abf838c8ca48/html5/thumbnails/8.jpg)
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
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Hazards of multivessel stenting
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Hazards of multivessel stenting
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Hazards of multivessel stenting
Orlic et al, JACC 2004
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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?
![Page 13: Multivessel PCI on top of culprit lesion revascularization? No way!](https://reader036.vdocument.in/reader036/viewer/2022062518/5697bf8e1a28abf838c8ca48/html5/thumbnails/13.jpg)
PCI based only on oculostenotic reflex is not justified in stable MVD
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Boden et al, NEJM 2007
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Boden et al, NEJM 2007
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Boden et al, NEJM 2007
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Boden et al, NEJM 2007
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Even symptomatic benefits are only marginal in unselected patients
Boden et al, NEJM 2007
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Would you trust an hazard ratio of 1.15?
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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?
![Page 23: Multivessel PCI on top of culprit lesion revascularization? No way!](https://reader036.vdocument.in/reader036/viewer/2022062518/5697bf8e1a28abf838c8ca48/html5/thumbnails/23.jpg)
PCI based only on oculostenotic reflex is also not justified in acute MVD
Hirsch et al, Lancet 2007
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Hirsch et al, Lancet 2007
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Hirsch et al, Lancet 2007
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Hirsch et al, Lancet 2007
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Hirsch et al, Lancet 2007
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Multivessel PCI in acute MVD: incremental benefits or costs?
Brener et al, Am J Cardiol 2002
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Brener et al, Am J Cardiol
2002
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Brener et al, Am J Cardiol
2002
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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.
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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
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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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For further slides on these topics For further slides on these topics please feel free to visit the please feel free to visit the
metcardio.org website:metcardio.org website:
http://www.metcardio.org/slides.html