1. Multivessel PCI on top of culprit lesion revascularization? No way!

2. 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?

3. Let us begin with an example from a related field…

4. Is it safer to target one only?

6. Or all of them at once?

7. 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?

8. 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

9. Hazards of multivessel stenting

11. Orlic et al, JACC 2004

12. 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?

13. PCI based only on oculostenotic reflex is not justified in stable MVD

14. Boden et al, NEJM 2007

18. Even symptomatic benefits are only marginal in unselected patients Boden et al, NEJM 2007

19. Would you trust an hazard ratio of 1.15?

22. 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?

23. PCI based only on oculostenotic reflex is also not justified in acute MVD Hirsch et al, Lancet 2007

28. Multivessel PCI in acute MVD: incremental benefits or costs? Brener et al, Am J Cardiol 2002

31. 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.

32. 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

33. 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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