Читать книгу Practical Cardiovascular Medicine - Elias B. Hanna - Страница 38

 One- or two-vessel disease (≥50%)

 PCI is an alternative to CABG in three-vessel CAD or complex two-vessel CAD involving the LAD with a SYNTAX score ≤ 22 and no diabetes.⁷⁶ Multivessel PCI (including proximal LAD PCI) compares favorably with CABG if the stenoses’ morphology and location are technically amenable to PCI and if full functional revascularization can be achieved with PCI.⁷⁸ The presence of a chronic total occlusion, one or more technically difficult or long lesions, or diabetes, should favor CABG, especially because CABG provides a more complete revascularization.

NSTEMI with multivessel CAD: single-stage multivessel PCI vs. culprit-only PCI:

When multiple complex lesions are seen in NSTEMI, the culprit artery may not be clearly identified and multivessel intervention is justified. According to a MRI analysis, the culprit artery is misidentified by catheterization in 35% of patients.⁷⁹ The SMILE trial randomized NSTEMI patients with multivessel disease to multivessel PCI in one stage vs. multiple stages (2^nd procedure 3-7 days later). Despite a similarly complete revascularization with only a few days difference, single-stage PCI was associated with significantly less repeat revascularizations at 1 year and a strong trend toward less deaths.⁸⁰ Large registry analyzes are concordant with SMILE findings.^81,82 As such, ESC recommends complete revascularization in NSTEMI with multivessel CAD, but allows flexible timing (class IIa).⁴

Somewhat similarly, in STEMI, multivessel PCI is to be performed; yet it does not have to be performed in the same setting and may await few days or weeks (COMPLETE, DANAMI-PRIMULTI trials).^83,84