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Complete versus culprit vessel percutaneous coronary intervention in multivessel disease: a randomized comparison
Alexander J J Ijsselmuiden1, JanPaul Ezechiels, Iris C D Westendorp
1Amsterdam Department of Interventional Cardiology OLVG Hospital, Amsterdam, The Netherlands. a.j.j.ijsselmuiden@olvg.nl
Insights
Complete revascularization in multivessel coronary artery disease (CAD) had lower initial success but similar long-term outcomes compared to culprit-only PCI. Costs equalized over time, suggesting individualized treatment decisions for CAD patients.
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Medicine
Background:
- Multivessel coronary artery disease (CAD) presents complex treatment challenges.
- Percutaneous coronary interventions (PCI) are a common revascularization strategy for CAD.
- Comparing complete versus culprit-only revascularization is crucial for optimizing patient outcomes and resource allocation.
Purpose of the Study:
- To compare the safety, efficacy, and economic impact of complete versus culprit-vessel revascularization in multivessel CAD.
- To evaluate major adverse cardiac events (MACE) and procedural success rates.
- To analyze costs associated with each revascularization strategy.
Main Methods:
- Randomized trial comparing complete revascularization (n=108) versus culprit-vessel-only PCI (n=111) in patients with multivessel CAD.
- Primary endpoint: Major Adverse Cardiac Events (MACE) including death, myocardial infarction, need for bypass surgery, and repeat PCI up to 1 year.
- Long-term follow-up assessed outcomes and costs.
Main Results:
- Strategy success was higher in the culprit-vessel group (93.7%) versus complete revascularization (81.5%).
- Major Adverse Cardiac Events (MACE) rates were similar between groups at 24 hours, 1 month, 1 year, and long-term follow-up (4.6 years).
- Initial procedural costs were lower with culprit-vessel PCI, but costs equalized within 1 year due to more repeat PCIs in this group.
Conclusions:
- Complete revascularization in multivessel CAD treated with PCI showed lower initial strategy success but similar long-term MACE rates compared to culprit-vessel revascularization.
- While culprit-vessel PCI had lower initial costs, repeat procedures led to cost equalization within a year.
- Treatment decisions for multivessel CAD should be individualized based on patient-specific factors.
Background:
The purpose of this study was to compare the safety, efficacy, and costs of complete versus "culprit" vessel revascularization in multivessel coronary artery disease treated with percutaneous coronary interventions (PCI).
Methods:
Patients with multivessel disease and an identified culprit vessel were randomly assigned to complete revascularization of vessels > or =50% stenoses (n = 108) versus revascularization limited to the culprit vessel (n = 111). The primary end point, major adverse cardiac events (MACE), were defined as cardiac or noncardiac death, myocardial infarction, need for coronary artery bypass graft surgery, and repeat PCI up to 1 year.
Results:
Despite equal MACE at 24 hours (6.3% vs 7.4%), strategy success was higher in the culprit vessel than in the complete revascularization group (93.7% vs 81.5%, P =.007). MACE rates at 1 month (14.4% vs 9.3%), 1 year (32.4% vs 26.9%), and 4.6 +/- 1.2 years (40.4% vs 34.6%) were similar in both groups. Repeat PCI was performed more often in the culprit vessel group (31.2% vs 21.2%, P =.06). A lower consumption of medical material was associated with lower procedural costs in the culprit vessel group (5784 vs 7315 Euros; P <.001). However, between 1 year and the end of follow-up, costs had equalized in both groups.
Conclusions:
Complete versus culprit vessel revascularization in multivessel coronary disease treated with PCI was associated with a lower strategy success rate, similar MACE rates, and initially higher costs. However, over the long term, more repeat PCIs were conducted in patients treated by culprit revascularization only, mostly because of the need to treat lesions initially left untreated. As a consequence, incremental costs had equalized within 1 year. The decision of whether to perform culprit vessel or complete revascularization can be made on an individual basis.
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