When PCI is used to treat multivessel coronary artery disease (CAD), single-vessel or multivessel interventions can be performed in one or more stages. About half of all patients with CAD have blockages in multiple arteries, and as many as 20% of those undergoing PCI receive treatment in more than one vessel. The choice of strategy may influence safety and efficacy, convenience for patients, and cost and reimbursement. In some cases, careful consideration will lead to a single-vessel PCI, and other lesions will be managed medically. In others, multivessel PCI may be considered in the same procedure or in multiple stages.
Every patient who undergoes PCI should receive optimal therapy for coronary disease, ideally before starting the procedure.
Guidance From SCAI for PCI
Splitting PCI into separate sessions is less convenient for patients and more costly to insurers. As a result, cardiologists may feel pressured into doing too much in one session, which can be dangerous for some patients. In the November 9, 2011 issue of Catheterization and Cardiovascular Interventions, the Society for Cardiovascular Angiography and Interventions (SCAI) published a comprehensive consensus document that reviews treatment options for patients with multivessel CAD. Recommendations are also provided for the treatment of multiple vessels in one or multiple stages. The goal of the SCAI document is to offer guidance for treating these patients. It is designed to ensure that every step of PCI is as safe as possible and appropriate for each patient’s individual health condition (see also, Reducing Cardiovascular Events After PCI).
The document provides several recommendations for treating multivessel CAD:
Medical therapy: Every patient who undergoes PCI should receive optimal therapy for coronary disease, ideally before starting the procedure. For patients with residual significant lesions and angina after the first stage of planned multistage PCI, therapy should include a trial of antianginal agents to control symptoms.
Informed consent: Multivessel PCI at the time of diagnostic catheterization should be considered only if informed consent includes the risks and benefits of multivessel PCI as well as the risks and benefits of alternative treatments.
PCI strategy: When considering multivessel PCI, interventionists should develop a strategy regarding which stenoses to treat or evaluate. They should also identify the order, method, and timing of treating or evaluating the stenoses. This strategy should maximize patient benefits, minimize patient risk, and consider the other individual health factors that patients may have.
Flexibility of PCI strategy: The PCI treatment strategy should be flexible. For planned multivessel PCI, additional vessels should be treated only if the first vessel is treated successfully and if anticipated contrast and radiation doses and patient and operator conditions are favorable. Otherwise, it’s reasonable to defer PCI of the additional vessels. Conversion to a multivessel PCI strategy may be appropriate for patients with STEMI or cardiogenic shock in whom single-vessel culprit lesion PCI fails to relieve ongoing ischemia.
Reassessment between stages of multistage PCI: After the first stage of planned multistage PCI, the need for subsequent PCI should be reviewed before it’s performed.
Importantly, third party payers and quality auditors should recognize that multistage PCI for multivessel CAD is not an indication of poor quality. It also isn’t an attempt to increase reimbursement. While revascularization strategies should be justifiable, these recommendations from SCAI are important because they help protect the judgment of operators in selecting the best strategy for patients.
Readings & Resources (click to view)
Campeau L. Percutaneous radial artery approach for coronary angiography. Cathet Cardiovasc Diagn. 1989;16:3-7.
Kiemeneij F, Laarman GJ, Odekerken D, et al. A randomized comparison of percutaneous transluminal coronary angioplasty by the radial, brachial and femoral approaches: the ACCESS study. J Am Coll Cardiol. 1997;29:1269-1275.
Rao SV, Eikelboom JA, Granger CB, Harrington RA, Califf RM, Bassand JP. Bleeding and blood transfusion issues in patients with non-ST-segment elevation acute coronary syndromes. Eur Heart J. 2007;28:1193-1204.
Schussler JM. Effectiveness and safety of transradial artery access for cardiac catheterization. Proc (Bayl Univ Med Cent). 2011;24:205-209.
Jen HL, Yin WH, Chen KC, et al. Transradial approach in myocardial infarction. Acta Cardiol. 2011;66:239-245.