Читать книгу Interventional Cardiology - Группа авторов - Страница 298

Radial access is preferred for NSTE‐ACS patients, if feasible [14]. The Minimizing Adverse Hemorrhagic Events by Transradial Access Site and Systemic Implementation of Angiox (MATRIX) trial randomized 8404 patients with ACS to radial vs femoral access and reported lower incidence of major bleeding and mortality at 30 days. In subgroup analysis, NSTE‐ACS patients benefited the most from the intervention while no difference was evident in the STEMI group [18]. In single‐vessel CAD, ad hoc PCI should be performed, while in multivessel CAD (more than 50% of cases) the alternative of coronary artery bypass grafting (CABG) should be considered. For hemodynamically unstable patients with very high‐risk features that have to be revascularized in a timely fashion PCI is usually preferred. On the contrary, stable patients with complex anatomy (high SYNTAX score or left main disease) should be evaluated by a Heart Team before determining the optimal treatment strategy [19]. In this setting, patients undergoing PCI have been shown to be at lower risk for peri‐procedural stroke, MI, major bleeding, or renal injury, higher risk for ischemia driven repeat revascularization, and similar risk of death [20,21]. Regardless of the approach, achievement of complete revascularization (CR) is preferable if technically feasible. A meta‐analysis of 35 studies including 89,883 patients demonstrated an association of CR with lower long‐term morbidity and mortality [22]. Rathod et. al. examined 21 857 NSTEMI patients and reported that CR was associated with higher 5‐year survival, despite higher in‐hospital mortality [23]. According to the results of the Single‐Staged Compared With Multi‐Staged PCI in Multivessel NSTEMI Patients (SMILE) trial, complete 1‐stage revascularization was superior to staged revascularization in reducing the incidence of major adverse cardiovascular and cerebrovascular events (23.2% vs 13.6%; p= 0.004) in 584 NSTE‐ACS patients [24]. Finally, identification of significant lesions may be challenging and could be facilitated by intravascular imaging (especially with optical coherence tomography) to identify the underlying pathology (thrombus, plaque rupture, plaque erosion etc.) and guide management [].