Complete versus incomplete coronary revascularization: definitions, assessment and outcomes

• Published in: Nature reviews cardiology 2021-03, Vol.18 (3), p.155-168
• Main Authors: Gaba, Prakriti, Gersh, Bernard J., Ali, Ziad A., Moses, Jeffrey W., Stone, Gregg W.
• Format: Article
• Language: English
• Subjects: 692/4019/2776; 692/699/75/593/15/1939; 692/700/565/545; Cardiac Imaging; Cardiac Surgery; Cardiology; Cardiovascular disease; Care and treatment; Complications and side effects; Coronary heart disease; Coronary vessels; Medicine; Medicine & Public Health; Myocardial revascularization; Patient outcomes; Review Article; Stents; Surgery; Transluminal angioplasty
• ISSN: 1759-5002; 1759-5010
• DOI: 10.1038/s41569-020-00457-5

Coronary artery disease is the leading cause of morbidity and mortality worldwide. Selected patients with obstructive coronary artery disease benefit from revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery. Many (but not all) studies have demonstrated increased survival and greater freedom from adverse cardiovascular events after complete revascularization (CR) than after incomplete revascularization (ICR) in patients with multivessel disease. However, achieving CR after PCI or CABG surgery might not be feasible owing to patient comorbidities, anatomical factors, and technical or procedural considerations. These factors also mean that comparisons between CR and ICR are subject to multiple confounders and are difficult to understand or apply to real-world clinical practice. In this Review, we summarize and critically appraise the evidence linking various types of ICR to adverse outcomes in patients with multivessel disease and stable ischaemic heart disease, non-ST-segment elevation acute coronary syndrome or ST-segment elevation myocardial infarction, with or without cardiogenic shock. In addition, we provide practical recommendations for revascularization in patients with high-risk multivessel disease to optimize their long-term clinical outcomes and identify areas requiring future clinical investigation. In this Review, Stone and colleagues compare the outcomes after complete or incomplete revascularization with PCI or CABG surgery in patients with multivessel disease and stable ischaemic heart disease, NSTE-ACS or STEMI, with or without cardiogenic shock. Key points In most studies, incomplete revascularization of coronary arteries after percutaneous coronary intervention or coronary artery bypass graft surgery has been associated with a poor prognosis, although the benefit of striving to achieve complete revascularization in all patients is uncertain. In most patients with multivessel disease and stable ischaemic heart disease or non-ST-segment elevation acute coronary syndrome, long-term outcomes are improved by the complete revascularization of all haemodynamically significant flow-limiting lesions. In patients with multivessel disease and ST-segment elevation myocardial infarction without cardiogenic shock, achieving early and complete revascularization reduces the long-term rates of re-infarction and unplanned repeat revascularization. In patients with multivessel disease and ST-segment el