From the Guidelines
Staged percutaneous coronary intervention (PCI) is recommended for select patients presenting with an ST-segment–elevation myocardial infarction to improve outcomes, particularly those with significantly stenosed non-culprit arteries. The indications for staged PCI include patients with multivessel coronary artery disease who cannot safely undergo complete revascularization in a single procedure 1.
Key Indications
- Patients with ST-elevation myocardial infarction (STEMI) and multivessel disease, where treating the culprit lesion first and addressing non-culprit lesions in a subsequent procedure has shown improved outcomes 1.
- Patients with high anatomical complexity, such as multiple complex lesions or chronic total occlusions.
- Patients with hemodynamic instability during the initial procedure.
- Patients with contrast volume limitations to prevent contrast-induced nephropathy.
- Patients with prolonged procedure time leading to patient or operator fatigue.
- Patients with radiation exposure concerns.
Patient Selection
The decision to stage PCI should be individualized based on patient risk factors, lesion complexity, and procedural considerations 1. Patients with chronic kidney disease may benefit from staging to allow renal recovery between contrast exposures.
Medical Therapy
Between staged procedures, patients should remain on optimal medical therapy, including dual antiplatelet therapy, such as aspirin and a P2Y12 inhibitor 1. Staging allows for better procedural planning, reduced complications, and improved patient outcomes by balancing the need for complete revascularization with patient safety.
From the Research
Indications for Staged Percutaneous Coronary Intervention (PCI)
The decision to perform staged PCI is based on various factors, including the extent of coronary artery disease, the presence of comorbidities, and the patient's preferences. Some of the indications for staged PCI include:
- Multivessel coronary artery disease (MVCAD) with multiple lesions that require treatment 2
- Patients with complex coronary anatomy who are not suitable for coronary artery bypass grafting (CABG) 3
- Patients who prefer a less invasive procedure with a shorter recovery time 3
- Patients with stable angina who have high-risk lesions and are not suitable for CABG 4
- Patients with multivessel disease who have one or two hemodynamically significant lesions as identified by fractional flow reserve (FFR) < 0.75 5
Patient Preferences and Clinical Variables
Patient preferences play a significant role in the decision-making process for staged PCI. Studies have shown that patients who have undergone both CABG and PCI prefer staged PCI due to its less invasive nature and shorter recovery time 3. Clinical variables such as age, gender, diabetes mellitus, and previous myocardial infarction also influence the choice of revascularization strategy 4. For example, women and patients with diabetes mellitus are at increased risk of subsequent revascularization after PCI.
Comparison with Coronary Artery Bypass Grafting (CABG)
Staged PCI is often compared to CABG in terms of outcomes and effectiveness. While CABG offers more complete revascularization and better freedom from repeat revascularization, PCI has the advantage of being less invasive and having a shorter recovery time 6. The choice between staged PCI and CABG depends on various factors, including the extent of coronary artery disease, the presence of comorbidities, and the patient's preferences. Studies have shown that staged PCI can be an effective treatment strategy for patients with multivessel disease, with outcomes similar to those of CABG 5.