What is the recommended approach for patients requiring multiple stents across multiple vessels?

From the Guidelines

For patients requiring multiple stents across multiple vessels, a staged approach is generally recommended rather than attempting complete revascularization in a single procedure. This approach is supported by the 2021 ACC/AHA/SCAI guideline for coronary artery revascularization 1, which emphasizes the importance of treating the culprit lesion or most critical stenosis first, followed by subsequent procedures to address remaining vessels. The initial procedure should focus on treating the most critical stenosis, and subsequent procedures can be performed after allowing recovery time between interventions, typically 4-8 weeks.

Key Considerations

• The staged approach reduces procedural time, contrast load, and radiation exposure while minimizing the risk of contrast-induced nephropathy and periprocedural complications.
• Dual antiplatelet therapy (DAPT) with aspirin 81mg daily indefinitely plus a P2Y12 inhibitor should be initiated and maintained throughout the staged procedures.
• The duration of DAPT depends on stent type and patient risk factors but typically ranges from 6-12 months for drug-eluting stents.
• For complex multi-vessel disease, particularly in patients with diabetes or left main involvement, a Heart Team approach involving both interventional cardiologists and cardiac surgeons should evaluate whether coronary artery bypass grafting might be more appropriate than multiple stenting procedures.

Additional Options

• Hybrid coronary revascularization, which combines coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI), may be considered as an alternative to multi-vessel PCI or CABG in certain patients 1.
• Vascular brachytherapy is another option for patients with recurrent in-stent restenosis who are not good candidates for bypass surgery or have unfavorable anatomy for another drug-eluting stent 1.

Stent Selection

• The choice of stent type, such as drug-eluting stents (DES) or bare-metal stents (BMS), should be based on patient-specific factors, including the risk of restenosis and the need for dual antiplatelet therapy.
• Everolimus-eluting stents have been shown to have the best efficacy among DES types 1.

From the Research

Patients Requiring Multiple Stents Across Multiple Vessels

• The recommended approach for patients requiring multiple stents across multiple vessels is not explicitly stated in the provided studies, but some insights can be gathered from the available evidence.
• A study from 2009 2 compared the outcomes of single stent and multiple stent placements in patients undergoing percutaneous coronary intervention (PCI). The results showed that patients who required multiple stents had a higher incidence of major adverse cardiac events (MACEs) compared to those who received a single stent.
• However, another study from 2013 3 discussed the use of dual antiplatelet therapy (DAPT) with prasugrel or ticagrelor versus clopidogrel in patients with acute coronary syndrome (ACS) undergoing PCI with stent implantation. The study suggested that prasugrel or ticagrelor plus aspirin should be the DAPT of choice in patients with ACS undergoing PCI, unless they are at particularly high risk of bleeding.
• More recent studies, such as the TWILIGHT-CABG study from 2022 4, have investigated the use of ticagrelor with and without aspirin in patients with a prior coronary artery bypass graft (CABG) undergoing PCI. The results showed that ticagrelor monotherapy reduced bleeding without compromising ischemic outcomes compared to ticagrelor plus aspirin in high-risk patients with prior CABG.
• Other studies, such as the one from 2021 5, have discussed the role of anticoagulation and antiplatelet therapy in secondary prevention after CABG. The study suggested that DAPT with aspirin and clopidogrel/ticagrelor/prasugrel does not lead to improved graft patency rates or clinical outcomes after CABG over aspirin monotherapy.
• Another study from 2021 6 compared the effect of aspirin plus ticagrelor versus aspirin plus clopidogrel on saphenous vein graft (SVG) patency within 1 year after CABG. The results showed that both DAPT strategies maintained a fairly high graft patency rate in the early phase after CABG, regardless of CYP2C19 genotypes.

Key Considerations

• The choice of DAPT strategy should be individualized based on the patient's risk of bleeding and ischemic events.
• The use of prasugrel or ticagrelor plus aspirin may be beneficial in patients with ACS undergoing PCI, unless they are at high risk of bleeding.
• Ticagrelor monotherapy may be a viable option for high-risk patients with prior CABG undergoing PCI, as it reduces bleeding without compromising ischemic outcomes.
• Further studies are needed to determine the optimal DAPT strategy for patients requiring multiple stents across multiple vessels.