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  • Review Article
  • Published:

Complete versus incomplete coronary revascularization: definitions, assessment and outcomes

Nature Reviews Cardiology volume 18, pages 155–168 (2021)Cite this article

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Abstract

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.

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 elevation myocardial infarction with cardiogenic shock, attempting to achieve complete revascularization during the index procedure might increase the risk of renal injury and death; delayed complete revascularization after initial medical stabilization is a reasonable strategy.

  • Ongoing, large-scale, randomized trials will further inform the clinical effects of and optimal strategies for complete revascularization.

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Fig. 1: ICR versus CR in the ACUITY trial.
Fig. 2: Estimated 5-year event rates after PCI according to the residual SYNTAX score in the SYNTAX trial.
Fig. 3: rSS as a function of the baseline SYNTAX score in the ACUITY trial.
Fig. 4: Effect of anatomical ICR in patients with MVD and ischaemic CR.
Fig. 5: Outcomes after complete versus incomplete revascularization in patients with STEMI.
Fig. 6: CR versus ICR in patients with multivessel disease and STEMI.

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Authors and Affiliations

  1. NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA

    Prakriti Gaba, Ziad A. Ali & Jeffrey W. Moses

  2. Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA

    Bernard J. Gersh

  3. Cardiovascular Research Foundation, New York, NY, USA

    Ziad A. Ali, Jeffrey W. Moses & Gregg W. Stone

  4. The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA

    Gregg W. Stone

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P.G. and G.W.S. researched data for the article and discussed its content. P.G. wrote the manuscript, and all the authors reviewed and edited it before submission.

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Correspondence to Gregg W. Stone.

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Z.A.A. reports institutional research grants to Columbia University from Abbott, Acist and Cardiovascular Systems; serves as a consultant to Abbott, Acist, Boston Scientific, Cardinal Health, Cardiovascular Systems, Opsens and Spectrawave; and has equity in Shockwave Medical. G.W.S. has received speaker or other honoraria from Cook, Orchestra Biomed, Qool Therapeutics and Terumo; has served as a consultant to Abiomed, Ablative Solutions, Ancora, Cardiomech, Gore, HeartFlow, MAIA Pharmaceuticals, Matrizyme, Miracor, Neovasc, Reva, Robocath, TherOx, Valfix, Vascular Dynamics, Vectorious and V-Wave; and has equity/options from Applied Therapeutics, Ancora, Aria, Biostar family of funds, Cagent, Cardiac Success, MedFocus family of funds, Orchestra Biomed, Qool Therapeutics, SpectraWave and Valfix. The other authors declare no competing interests.

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Gaba, P., Gersh, B.J., Ali, Z.A. et al. Complete versus incomplete coronary revascularization: definitions, assessment and outcomes. Nat Rev Cardiol 18, 155–168 (2021). https://doi.org/10.1038/s41569-020-00457-5

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