Multivessel coronary artery disease
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Joanna J. Wykrzykowska, MD [2]; Robert Sperling, MD; Brian Bigelow, MD; Roger J. Laham, MD [3]
See also the chapter on Chronic stable angina revascularization
Overview
Multi-vessel coronary artery disease (CAD) is a disease stage in which at least two or three of the epicardial coronary arteries are involved with atherosclerosis of significant severity. Multivessel disease is often associated with a higher burden of comorbidities, left ventricular dysfunction, and cardiovascular risk.[1]
The goal in the treatment of multivessel disease is to reduce angina and heart failure symptoms and to reduce a patient's subsequent risk of adverse cardiovascular events. In general, PCI may be preferred in patients with single or low-risk two-vessel disease. In contrast, coronary artery bypass grafting (CABG) is recommended in patients with complex two-vessel disease, three-vessel disease, and significant left main disease, particularly when anatomic complexity is high.[1] Patients with diabetes mellitus and multivessel disease involving the left anterior descending (LAD) artery derive a survival benefit from CABG with a left internal mammary artery (LIMA) graft to the LAD.[2]
A multidisciplinary Heart Team approach, including representatives from interventional cardiology, cardiac surgery, and clinical cardiology, is recommended (Class I, LOE B-NR) when the optimal treatment strategy is unclear.[1]
Risk Stratification: The SYNTAX Score
The SYNTAX score (Synergy Between PCI With TAXUS and Cardiac Surgery) is the most widely used and validated risk score to guide the choice of revascularization in patients with multivessel disease (Class 2b, LOE B-NR).[1] It provides an objective measure of the anatomic complexity of coronary artery disease:
| SYNTAX Score Category | Score Range | Preferred Revascularization Strategy |
|---|---|---|
| Low | 0–22 | PCI or CABG (similar outcomes) |
| Intermediate | 23–32 | Heart Team discussion; CABG generally preferred |
| High | ≥33 | CABG recommended over PCI (Class 2a, LOE B-R) |
Important limitations of the SYNTAX score include the cumbersome scoring system, interobserver variability, and the absence of clinical variables, which limits its use in estimating risk after CABG.[1] The SYNTAX II Score and SYNTAX Score II 2020 were retrospectively developed to incorporate clinical variables in addition to anatomic variables, though they demonstrate only modest discrimination in predicting adverse events.[1]
Angiographic features contributing to increasing complexity include:
Multivessel disease
Left main or proximal LAD lesion
Complex bifurcation or trifurcation lesion
Heavy calcification
Severe tortuosity
Aorto-ostial stenosis
Diffusely diseased and narrowed segments distal to the lesion
In patients with diabetes mellitus, the SYNTAX score should not be used as the sole determinant of revascularization strategy, as the FREEDOM trial demonstrated that CABG was superior to PCI across all SYNTAX score tertiles.[3]
Medical Therapy
All patients with multivessel coronary artery disease, whether they undergo PCI, CABG, or neither, should receive guideline-directed medical therapy (GDMT) to reduce cardiovascular event risk and angina.[4]
Antiplatelet Therapy
Aspirin: Low-dose aspirin 81 mg (75–100 mg) is recommended (Class I, LOE A) in patients with chronic coronary disease and no indication for oral anticoagulant therapy to reduce atherosclerotic events.[4]
Dual antiplatelet therapy (DAPT): Aspirin plus clopidogrel for 6 months post-PCI with drug-eluting stents (DES), followed by single antiplatelet therapy (SAPT), is indicated (Class I, LOE A) to reduce MACE and bleeding events.[4]
P2Y12 inhibitor monotherapy: In select patients who have completed a 1- to 3-month course of DAPT after PCI with DES, P2Y12 inhibitor monotherapy for at least 12 months is reasonable (Class 2a, LOE A) to reduce bleeding risk.[4]
Extended DAPT: In patients with prior MI and low bleeding risk, extended DAPT beyond 12 months for up to 3 years may be reasonable (Class 2b, LOE A) to reduce MACE.[4]
Antiplatelet Therapy in Acute Coronary Syndromes
Per the 2025 ACC/AHA/ACEP/NAEMSP/SCAI ACS Guideline:
In patients with ACS who are not at high bleeding risk, DAPT with aspirin and an oral P2Y12 inhibitor should be administered for at least 1 year (Class I, LOE B-R) to reduce MACE.[5]
In patients with STEMI managed with primary PCI, prasugrel or ticagrelor is recommended to reduce MACE and stent thrombosis (Class I, LOE B-R).[5]
In patients with NSTE-ACS undergoing PCI, prasugrel or ticagrelor is recommended to reduce MACE and stent thrombosis (Class I, LOE B-R).[5]
In patients with ACS who have tolerated DAPT with ticagrelor, transition to ticagrelor monotherapy ≥1 month post-PCI is useful to reduce bleeding risk (Class I, LOE B-R).[5]
Lipid-Lowering Therapy
Statins remain first-line therapy for lipid-lowering in patients with chronic coronary disease.[4]
Adjunctive therapies including ezetimibe, PCSK9 inhibitors, inclisiran, and bempedoic acid may be used in select populations, although clinical outcomes data are unavailable for some novel agents such as inclisiran.[4]
Per the 2025 ACS Guideline, in patients with ACS already on maximally tolerated statin therapy with LDL-C ≥70 mg/dL (≥1.8 mmol/L), adding a nonstatin lipid-lowering agent is recommended (Class I, LOE A) to further reduce the risk of MACE.[5]
Antianginal Therapy
Either a calcium channel blocker or beta blocker is recommended as first-line antianginal therapy (Class I, LOE B-R).[4]
In patients who remain symptomatic, addition of a second antianginal agent from a different therapeutic class (beta blockers, CCBs, long-acting nitrates) is recommended (Class I, LOE B-R).[4]
Ranolazine is recommended in patients who remain symptomatic despite treatment with beta blockers, CCBs, or long-acting nitrate therapies (Class I, LOE B-R).[4]
Sublingual nitroglycerin or nitroglycerin spray is recommended for immediate short-term relief of angina (Class I, LOE B-NR).[4]
Beta-Blocker Therapy: Updated Recommendations
Long-term beta blocker therapy is not recommended to improve outcomes in patients with chronic coronary disease in the absence of myocardial infarction in the past year, left ventricular ejection fraction ≤50%, or another primary indication for beta blocker therapy.[4]
Risk Factor Modification
Risk factor modification should be undertaken in all patients, including smoking cessation, treatment of hypertension, correction of dyslipidemia, and management of diabetes mellitus. Use of SGLT2 inhibitors and GLP-1 receptor agonists is recommended for select groups of patients with chronic coronary disease, including those without diabetes mellitus.[4]
The COURAGE Trial
The COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial randomized 2,287 patients with stable CAD (approximately two-thirds with multivessel disease) to an initial strategy of PCI plus optimal medical therapy versus optimal medical therapy alone. There was no significant difference in rates of death or myocardial infarction between the two groups. However, patients treated with medical therapy alone had an increased risk of angina and decreased quality of life, and approximately 30% eventually required revascularization.[6]
The ISCHEMIA Trial
The ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial randomized 5,179 patients with stable CAD and moderate-to-severe ischemia on stress testing to an initial invasive strategy (angiography and revascularization when feasible) plus medical therapy versus an initial conservative strategy of medical therapy alone. Over a median of 3.2 years, there was no significant difference in the primary composite outcome of cardiovascular death, myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest (HR 0.93; 95% CI 0.80–1.08).[7]
Key findings from ISCHEMIA include:
An early hazard of increased periprocedural myocardial infarction with the invasive strategy was offset by a late reduction in spontaneous MI (33% lower hazard).[8]
In prespecified subgroup analyses, none of the currently considered "high-risk" criteria (multivessel disease, proximal LAD involvement, or severe inducible ischemia) were associated with improved outcomes in the invasive versus conservative arms.[8]
The trial excluded patients with left main disease or LVEF <35%.[7]
In a secondary analysis, both PCI and CABG were associated with higher early risks but lower long-term risks of cardiovascular events compared with conservative management.[9]
The 2021 ACC/AHA/SCAI Guideline downgraded the recommendation for CABG to improve survival in stable 3-vessel disease with preserved LV function and no left main disease from Class I (in 2011) to Class 2b ("may be reasonable"), based in part on the ISCHEMIA trial results and newer meta-analyses.[1]
Revascularization Utilizing Coronary Artery Bypass Grafting (CABG)
When compared to medical therapy and percutaneous coronary intervention, CABG is associated with a lower incidence of recurrent angina and a lower need for repeat revascularization. CABG provides unique "field protection" by furnishing an alternative route for blood flow that is unhindered by upstream native CAD, thereby protecting distal myocardial beds from future ischemic insult caused by proximal plaque progression or rupture. PCI, in contrast, only treats the coronary artery segment where the stent is implanted.[4]
CABG Versus Medical Therapy
Several randomized trials of CABG versus medical therapy support the concept of greater absolute benefit associated with CABG with respect to long-term survival in patients with more extensive or proximal CAD, or in patients with impaired left ventricular function. Older trials were limited by low usage of internal mammary artery (IMA) grafting, antiplatelet agents, and a high cross-over of the medical treatment arm to CABG.
The STICH/STICHES Trial
The STICH (Surgical Treatment for Ischemic Heart Failure) trial randomized 1,212 patients with ischemic cardiomyopathy and LVEF ≤35% to CABG plus medical therapy versus medical therapy alone.[10]
| Outcome | CABG + Medical Therapy | Medical Therapy Alone | Hazard Ratio (95% CI) | P Value |
|---|---|---|---|---|
| All-cause mortality (10 years) | 58.9% | 66.1% | 0.84 (0.73–0.97) | 0.02 |
| Cardiovascular mortality (10 years) | 40.5% | 49.3% | 0.79 (0.66–0.93) | 0.006 |
| Death or CV hospitalization (10 years) | 76.6% | 87.0% | 0.72 (0.64–0.82) | <0.001 |
At 5 years, there was no significant difference in the primary outcome of all-cause mortality (HR 0.86; 95% CI 0.72–1.04; P=0.12). However, at 10 years, CABG demonstrated a significant reduction in all-cause mortality, cardiovascular mortality, and death or cardiovascular hospitalization, with an incremental median survival benefit of 18 months and a number needed to treat of 14.[10] The long-term survival benefit of CABG was most apparent in younger patients and those with more advanced disease (3-vessel disease, more severe left ventricular systolic dysfunction).[11]
REVIVED-BCIS2 Trial
In contrast, the REVIVED-BCIS2 trial found that PCI in patients with LVEF ≤35% did not improve MACE including survival at median 3.4 years versus optimal medical therapy alone.[4] A pooled individual patient data analysis of REVIVED-BCIS2 and STICHES found that patients receiving medical therapy alone in REVIVED-BCIS2 had better outcomes than those in STICHES (with or without CABG), likely reflecting improvements in contemporary medical therapy.[12]
Current Guideline Recommendations for CABG
Per the 2023 AHA/ACC Chronic Coronary Disease Guideline and the 2021 ACC/AHA/SCAI Revascularization Guideline:
Class I: CABG plus medical therapy is recommended over medical therapy alone for patients with significant left main disease or multivessel disease with severe left ventricular dysfunction (LVEF ≤35%) to improve survival.[4]
Class I: In patients requiring revascularization for significant left main CAD with high-complexity disease, CABG is recommended over PCI to improve survival.[1]
Class I: In patients with diabetes and multivessel CAD with involvement of the LAD who are appropriate candidates for CABG, CABG (with a LIMA to the LAD) is recommended in preference to PCI to reduce mortality and repeat revascularizations.[1][2]
Class 2a: In patients requiring revascularization for multivessel CAD with complex or diffuse disease (e.g., SYNTAX score >33), it is reasonable to choose CABG over PCI to confer a survival advantage.[1]
Class 2b: In stable patients with 3-vessel disease, preserved LV function, and no left main disease, CABG "may be reasonable" to improve survival (downgraded from Class I in 2011).[1]
CABG Versus PCI: The FREEDOM Trial in Diabetic Patients
The FREEDOM (Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease) trial randomized 1,900 patients with diabetes mellitus and multivessel disease (without left main disease) to PCI with drug-eluting stents versus CABG. The LAD had significant disease in 91% of patients, and 82–85% had 3-vessel disease.[1]
| Outcome | CABG | PCI | Significance |
|---|---|---|---|
| All-cause mortality (5 years) | Lower | Higher | P<0.05 |
| All-cause mortality (8 years, Follow-on) | 18.3% | 24.3% | P<0.05 |
| Nonfatal MI (5 years) | Lower | Higher | P<0.05 |
| Stroke (5 years) | Higher | Lower | P<0.05 |
The benefit of CABG appeared to be unrelated to the complexity of disease as measured by the SYNTAX score.[3] In the FREEDOM Follow-on Study at a mean of 7.5 years, the all-cause mortality rate remained significantly higher with PCI.[2] A meta-analysis including individual patient data from 11 RCTs demonstrated consistent results, with a nearly 50% higher 5-year mortality risk among patients with diabetes treated with PCI than among those treated with CABG.[1]
A large registry study (N≈33,000) of patients with diabetes and multivessel disease confirmed the trial findings, showing that CABG was associated with higher long-term survival and lower rates of major adverse cardiac and cerebrovascular events (MACCE) compared with PCI over 8 years of follow-up.[13]
Revascularization by Percutaneous Coronary Intervention (PCI)
PCI Versus Medical Therapy
The subgroup analysis of patients with stable, multivessel CAD in the COURAGE trial suggested no difference in death and MI rates between PCI- and medically-treated groups.[6] The ISCHEMIA trial confirmed that in patients with stable CAD and moderate-to-severe ischemia, an initial invasive strategy did not reduce the risk of ischemic cardiovascular events or death from any cause over a median of 3.2 years.[7]
The FAME 2 (Fractional Flow Reserve–Guided PCI versus Medical Therapy in Stable Coronary Disease) trial demonstrated that FFR-guided PCI (for lesions with FFR ≤0.80) was superior to medical therapy alone, primarily driven by a reduction in urgent revascularization, with benefit sustained over 5 years.[4]
The 2021 ACC/AHA/SCAI Guideline concluded that the ability of PCI to improve survival, compared with medical therapy alone in patients with multivessel CAD, remains uncertain.[1]
PCI Versus CABG
The SYNTAX Trial
The SYNTAX trial randomized 1,800 patients with 3-vessel or left main CAD to PCI with paclitaxel-eluting stents versus CABG. At 1 year, the primary composite adverse event rate was higher in the PCI group (17.8% vs. 12.4% for CABG; P=0.002), largely due to an increased rate of repeat revascularization (13.5% vs. 5.9%, P<0.001).[1]
Key long-term findings:
In the overall population, there was no significant difference in all-cause death between PCI and CABG.
In the 3-vessel disease subgroup: CABG provided a significant survival benefit over PCI (40% higher mortality with PCI at extended follow-up).[4]
In the left main subgroup: No significant survival difference between PCI and CABG.[1]
SYNTAX score ≤22: PCI outcomes were noninferior to CABG.
SYNTAX score ≥33: CABG was superior to PCI with lower all-cause mortality.[1]
Mortality and MI
Most studies comparing CABG and PCI have reported similar survival overall. However, certain subgroups derive a survival benefit from CABG compared with PCI, including patients with complex or diffuse CAD and those with diabetes mellitus.[4] Compared with PCI, CABG may be more effective at reducing the risk of late spontaneous MI.[1]
A collaborative analysis of data from 10 randomized controlled trials (N=7,812) was pooled to compare effectiveness of CABG with PCI in view of long-term effects on mortality in various clinical subgroups. PCI was done with balloon angioplasty in six trials and with bare metal stents in four trials. The results showed that long-term mortality is similar with PCI and CABG in most patient subgroups who had multivessel disease. CABG proved a better option in diabetics and elderly over 65 years.[14]
Recurrent Revascularization
The need for repeat revascularization is higher after PCI, regardless of the use of latest-generation DES.[1] Earlier trials using bare metal stents (ARTS I, MASS II, ERACI-II, AWESOME) showed similar survival rates but higher revascularization rates among patients with bare metal stents at 5 years compared with CABG.
Symptom Relief
CABG has been associated with greater relief of anginal symptoms compared with PCI.[1]
Costs
In comparison to CABG, PCI is less invasive, has a shorter hospital stay and convalescence, and has a less expensive initial hospital stay. However, the cost advantage may be lost over the long term due to the potential need for repeat revascularization.
Completeness of Revascularization
Observational data suggest worse outcomes with incomplete revascularization.[1] A patient-level pooled analysis of the SYNTAX, PRECOMBAT, and BEST trials demonstrated that PCI with complete revascularization showed survival comparable to CABG with complete revascularization, whereas PCI with incomplete revascularization had worse outcomes.[15] One must be confident in the ability to achieve complete revascularization with PCI when offering it as an alternative to CABG.
Physiologic Assessment: FFR and iFR
Fractional flow reserve (FFR) or instantaneous wave-free ratio (iFR) is recommended (Class I) before PCI for angiographically intermediate stenoses.[4] In the FAME trial, FFR-guided PCI reduced MACE compared with angiography-guided PCI in multivessel disease, a benefit maintained at 2 years but not statistically significant at 5 years.[16]
An updated meta-analysis of 8 RCTs (N=4,433) confirmed that FFR-guided PCI demonstrated significant long-term reductions in MACE (OR 0.76; 95% CI 0.60–0.96) and MI (OR 0.65; 95% CI 0.45–0.93) compared with angiography-guided PCI, with the benefit most pronounced in non-ACS patients.[17]
Multivessel PCI in Acute Coronary Syndromes
STEMI With Multivessel Disease: Complete Revascularization
In patients with STEMI and multivessel CAD who are hemodynamically stable, complete revascularization with multivessel PCI is recommended (Class I, LOE A) to reduce cardiovascular death and MI.[5]
The COMPLETE trial randomized 4,041 patients with STEMI and significant multivessel disease to staged PCI of the non-infarct-related artery (performed up to 45 days post-MI) versus culprit-vessel-only revascularization. At a median follow-up of 3 years, multivessel PCI reduced cardiovascular death or MI and cardiovascular death, MI, or ischemia-driven revascularization. This benefit was consistent across all subgroups.[5]
Timing of Non-Culprit Artery PCI in STEMI
The MULTISTARS AMI trial randomized 840 patients with STEMI and multivessel disease to immediate multivessel PCI versus staged multivessel PCI (19–45 days after index procedure). At 1 year, immediate multivessel PCI was noninferior and superior to staged multivessel PCI for the primary composite endpoint (8.5% vs. 16.3%; risk ratio 0.52; 95% CI 0.38–0.72; P<0.001 for superiority), largely driven by lower rates of recurrent MI and unplanned ischemia-driven revascularization.[18]
The BIOVASC trial similarly showed that immediate complete revascularization was noninferior to staged complete revascularization across the spectrum of acute coronary syndromes, including unstable angina, NSTEMI, and STEMI.[5]
Per the 2025 ACC/AHA ACS Guideline, in a network meta-analysis comparing all strategies for managing the non-infarct-related artery, a single-procedure approach for immediate multivessel PCI was preferred, followed by staged multivessel PCI. Patients ideally suited for immediate complete revascularization include those with uncomplicated PCI of the infarct-related artery and low-complexity non-infarct-related artery disease with stable hemodynamics, normal left ventricular filling pressures, and normal renal function.[5]
Important caveat: The benefits of complete revascularization with multivessel PCI should not be extrapolated to patients with disease more suited to CABG, as they were excluded from these trials. Few patients with complex disease such as chronic total occlusions or left main involvement were included.[5]
Cardiogenic Shock and Multivessel Disease
In patients with AMI complicated by cardiogenic shock and multivessel disease, culprit-lesion-only PCI with an option for staged revascularization is recommended over immediate multivessel PCI (Class I, LOE B-R).[5]
The CULPRIT-SHOCK trial randomized 706 patients with AMI (66% with STEMI) and cardiogenic shock to culprit-lesion-only PCI versus immediate multivessel PCI. Culprit-lesion-only PCI significantly reduced the composite of 30-day mortality or renal replacement therapy (45.9% vs. 55.4%; relative risk 0.83; 95% CI 0.71–0.96; P=0.01), driven primarily by an absolute 8.2% reduction in mortality. These results were sustained at 1-year follow-up.[19]
NSTE-ACS With Multivessel Disease
In patients with NSTE-ACS and multivessel disease, complete revascularization is reasonable (Class 2a, LOE B-R) to reduce MACE. The benefits of complete revascularization with multivessel PCI should not be extrapolated to patients with disease more suited to CABG.[5]
Selecting a Therapeutic Strategy or Strategies
Decision-Making Algorithm
The following algorithm summarizes the approach to selecting a revascularization strategy in patients with multivessel CAD:
| Step | Assessment | Action |
|---|---|---|
| 1 | All patients | Initiate guideline-directed medical therapy (GDMT) including antiplatelet therapy, statins, antianginal agents, and risk factor modification |
| 2 | Assess left ventricular function | If LVEF ≤35% with multivessel disease → CABG recommended (Class I) to improve survival |
| 3 | Assess for left main disease | If significant left main disease with high complexity → CABG recommended (Class I); if low-to-intermediate complexity → Heart Team discussion |
| 4 | Assess for diabetes mellitus | If diabetes with multivessel disease involving LAD → CABG with LIMA to LAD recommended (Class I) |
| 5 | Assess anatomic complexity (SYNTAX score) | SYNTAX ≥33 → CABG preferred (Class 2a); SYNTAX 23–32 → Heart Team discussion; SYNTAX ≤22 → PCI or CABG reasonable |
| 6 | Assess clinical context | Consider patient preference, operative risk (STS score), life expectancy, comorbidities, ability to comply with DAPT, and feasibility of complete revascularization |
| 7 | Heart Team discussion | Recommended (Class I) when optimal strategy is unclear |
Optimal Medical Therapy
Risk factor modification should be undertaken in all patients (smoking cessation, treatment of hypertension, correction of dyslipidemia, management of diabetes mellitus).
Optimal medical therapy should be advised for all patients. Medical therapy may be an acceptable choice as the sole treatment when left ventricular systolic function is normal or mildly depressed, and when the lifestyle is acceptable with medical therapy.
Revascularization is chosen when unacceptable symptoms persist despite optimal medical therapy and when lesions and risk factors are present for which revascularization improves morbidity and mortality compared with medical therapy (e.g., a left main lesion).[4]
Scenarios Favoring CABG Over Medical Therapy to Prolong Survival
Multivessel disease and left ventricular systolic dysfunction (LVEF ≤35%)
3-vessel disease with proximal LAD stenosis regardless of LV function
2-vessel disease and left ventricular systolic dysfunction (especially with proximal disease and severe angina)[1]
Scenarios Favoring PCI Over CABG
CAD anatomy and complexity suitable for PCI (single or two-vessel disease, low SYNTAX score)
Younger patients who will likely require CABG in the future, in order to delay the inevitable surgery
Limited life expectancy
High operative risk (including cerebrovascular disease, severe COPD, or other illnesses limiting survival)
Poor graft conduits (no IMA available or poor vein quality)
Patient prefers to avoid surgery
In non-diabetic patients with 3-vessel disease and poor left ventricular systolic function, consider PCI in select patients with low-risk lesions if complete revascularization can be achieved. The risks and benefits of lifelong DAPT and risks of stent thrombosis must be discussed extensively with the patient. Stenting is not an ideal choice for the patient who is not compliant with medications such as P2Y12 inhibitors.[1]
Scenarios Favoring CABG Over PCI
In the presence of concurrent valvular disease requiring surgical repair
Complete functional revascularization unlikely to be achieved with PCI
Lesions not suitable for stenting (low likelihood of success, high risk of complications, high risk of restenosis)
Patient prefers to limit number of revascularization procedures
Patients with diabetes mellitus and multivessel disease: CABG is recommended because the FREEDOM trial showed improved survival after CABG compared with multivessel PCI with DES, with benefit sustained at 8 years (all-cause mortality 18.3% vs. 24.3%).[2] This benefit was consistent across all SYNTAX score tertiles.[3]
Complex or diffuse disease (SYNTAX score ≥33)[1]
Scenarios Favoring a Hybrid of CABG and PCI
Hybrid coronary revascularization (HCR) combines minimally invasive off-pump grafting of the LIMA to the LAD with PCI of the remaining vessels. The 2021 ACC/AHA/SCAI Guideline notes that small RCTs and observational studies with propensity-matching of HCR versus conventional CABG have found similar rates of death, MI, stroke, and repeat revascularization.[1]
A 10-year propensity-matched study (N=540 per group) showed that HCR performed similarly to off-pump CABG but significantly outperformed PCI in terms of MACCE (P<0.001). In the high EuroSCORE II stratum, HCR had a lower MACCE rate than both CABG (31.9% vs. 47.0%; P=0.041) and PCI (31.9% vs. 53.7%; P=0.015).[20]
Indications for a hybrid approach include:
Adjunctive PCI may be performed before or after CABG in lesions that are not amenable to coronary artery bypass grafting. This may include lesions in very distal arteries or lesions in very small vessels.
Due to higher CABG mortality in patients with UA/NSTEMI, a strategy of PCI to the "culprit artery" followed by elective revascularization (as needed) of the residual disease may be employed. Identification of the culprit artery requires localizing ECG, echocardiographic, or angiographic features (coronary thrombus, ulcerative plaque, slow flow, a high-grade stenosis, or pressure wire technique).
The role of hybrid surgery as an alternative to multivessel PCI or traditional CABG remains under investigation, as the Hybrid Coronary Revascularization trial was terminated early because of low enrollment.[1]
Technical Considerations in the Performance of Multivessel PCI
Staging of Procedures
One may need to stage the procedure because of contrast load and radiation dose, as well as procedure time.
Starting with the most challenging lesion in patients for whom CABG is an option may be advisable to evaluate feasibility of complete revascularization.
Assessment of patient's ability to comply with dual antiplatelet therapy is crucial, especially with bifurcation stenting, long lesions, and small vessels, which are common in patients with multivessel disease where risk of stent thrombosis is highest.
Intravascular Imaging
Intravascular imaging with intravascular ultrasound (IVUS) or optical coherence tomography (OCT) is recommended to guide PCI in complex CAD:
IVUS can be useful for procedural guidance, particularly in cases of left main or complex coronary artery stenting, to reduce ischemic events (Class 2a, LOE B-R).[1]
OCT is a reasonable alternative to IVUS for procedural guidance, except in ostial left main disease (Class 2a, LOE B-R).[1]
In patients with stent failure, IVUS or OCT is reasonable to determine the mechanism of stent failure (Class 2a, LOE C-LD).[1]
The RENOVATE-COMPLEX-PCI trial randomized 1,639 patients with complex coronary artery lesions 2:1 to intravascular imaging-guided PCI versus angiography-guided PCI. At a median follow-up of 2.1 years, intravascular imaging-guided PCI led to a lower risk of the composite of cardiac death, target-vessel-related MI, or clinically driven target-vessel revascularization (7.7% vs. 12.3%; HR 0.64; 95% CI 0.45–0.89; P=0.008).[21] At 5-year extended follow-up, the benefit was sustained (10.5% vs. 14.9%; HR 0.68; 95% CI 0.51–0.91; P=0.009), with particular benefit for hard clinical endpoints including cardiac death and target-vessel-related MI.[22]
Per the 2025 ACC/AHA ACS Guideline, intracoronary imaging guidance is recommended (Class I, LOE B-R) in patients with ACS undergoing PCI to reduce target-vessel failure.[5]
Physiologic Assessment During Multivessel PCI
FFR or iFR should be used to assess the hemodynamic significance of angiographically intermediate stenoses (40–70% diameter stenosis) before PCI (Class I, LOE A).[4]
Patients with FFR >0.80 or iFR >0.89 appear to have low event rates with medical therapy alone.[4]
FFR-guided PCI is superior to angiography-guided PCI for reducing MACE rates among patients with multivessel CAD.[4]
References
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- ↑ 3.0 3.1 3.2 Esper RB, Farkouh ME, Ribeiro EE, Hueb W, Domingos TA, Lopes NH, Soares PR, Jatene FB, Pereira AC, Lopes RD, Fuster V, Serruys PW, Gersh BJ (2018-12-11). "SYNTAX Score in Patients With Diabetes Undergoing Coronary Revascularization in the FREEDOM Trial". J Am Coll Cardiol. 72 (23): 2826–2837. doi:10.1016/j.jacc.2018.09.046. PMID 30545450.
- ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 4.12 4.13 4.14 4.15 4.16 4.17 4.18 4.19 4.20 4.21 4.22 4.23 Virani SS, Newby LK, Arnold SV, Bittner V, Brewer LC, Demeter SH, Dixon DL, Fearon WF, Hess B, Johnson HM, Kazi DS, Kolte D, Kumbhani DJ, LoFaso J, Mahtta D, Mark DB, Minissian M, Navar AM, Patel AR, Piano MR, Rodriguez F, Talber CE, Taqueti VR, Thomas RJ, van Diepen S, Wiggins B, Williams MS (2023-08-29). "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease". J Am Coll Cardiol. 82 (9): 833–955. doi:10.1016/j.jacc.2023.04.003. PMID 37471501 Check
|pmid=value (help). - ↑ 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 5.11 5.12 Rao SV, O'Donoghue ML, Ruel M, Bhatt DL, Cannon CP, de Winter RJ, Farkouh ME, Gilchrist IC, Harrington RA, Ibanez B, Kimura T, Kumbhani DJ, Lopes RD, Mehran R, Mukherjee D, Newby LK, Sabatine MS, Siontis G, Stone GW, Tamis-Holland JE, Thiele H, van Diepen S (2025-06-10). "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes". J Am Coll Cardiol. doi:10.1016/j.jacc.2025.01.013. PMID 40527516 Check
|pmid=value (help). Vancouver style error: initials (help) - ↑ 6.0 6.1 Boden WE, O'Rourke RA, Teo KK, Hartigan PM, Maron DJ, Kostuk WJ, Knudtson M, Dada M, Casperson P, Harris CL, Chaitman BR, Shaw L, Gosselin G, Nawaz S, Title LM, Gau G, Blaustein AS, Booth DC, Bates ER, Spertus JA, Berman DS, Mancini GB, Weintraub WS (2007-04). "Optimal medical therapy with or without PCI for stable coronary disease". N Engl J Med. 356 (15): 1503–16. doi:10.1056/NEJMoa070829. PMID 17387127. Check date values in:
|date=(help) - ↑ 7.0 7.1 7.2 Maron DJ, Hochman JS, Reynolds HR, Bangalore S, O'Brien SM, Boden WE, Chaitman BR, Senior R, López-Sendón J, Alexander KP, Lopes RD, Shaw LJ, Berger JS, Newman JD, Sidhu MS, Goodman SG, Ruzyllo W, Gosselin G, Maggioni AP, White HD, Bhargava B, Min JK, Mancini G, Berman DS, Picard MH, Kwong RY, Ali ZA, Mark DB, Spertus JA, Krishnan MN, Elghamaz A, Moorthy N, Hueb WA, Demkow M, Mavromatis K, Bockeria O, Peteiro J, Miller TD, Szwed H, Doerr R, Keltai M, Selvanayagam JB, Steg PG, Held C, Kohsaka S, Mavromichalis S, Kirby R, Jeffries NO, Harrell FE, Rockhold FW, Broderick S, Ferguson TB, Williams DO, Harrington RA, Stone GW, Rosenberg Y (2020-04-09). "Initial Invasive or Conservative Strategy for Stable Coronary Disease". N Engl J Med. 382 (15): 1395–1407. doi:10.1056/NEJMoa1915922. PMID 32227755 Check
|pmid=value (help). Vancouver style error: initials (help) - ↑ 8.0 8.1 Ferraro R, Latina JM, Alfaddagh A, Michos ED, Blaha MJ, Jones SR, Sharma G, Trost JC, Boden WE, Weintraub WS, Lima J, Blumenthal RS, Sharma D (2020-11-10). "Evaluation and Management of Patients With Stable Angina: Beyond the Ischemia Paradigm: JACC State-of-the-Art Review". J Am Coll Cardiol. 76 (19): 2252–2266. doi:10.1016/j.jacc.2020.08.078. PMID 33245408 Check
|pmid=value (help). Vancouver style error: initials (help) - ↑ Redfors B, Stone GW, Alexander JH, Bates ER, Bhatt DL, Chen S, Chiswell K, Harrington RA, Hochman JS, Maron DJ, Mark DB, O'Brien SM, Reynolds HR, Rosenberg Y, Sidhu MS, Williams DO, Bangalore S (2024-02-06). "Outcomes According to Coronary Revascularization Modality in the ISCHEMIA Trial". J Am Coll Cardiol. 83 (6): 549–561. doi:10.1016/j.jacc.2023.11.003. PMID 38325987 Check
|pmid=value (help). - ↑ 10.0 10.1 Velazquez EJ, Lee KL, Jones RH, Al-Khalidi HR, Hill JA, Panza JA, Michler RE, Bonow RO, Doenst T, Petrie MC, Oh JK, She L, Moore VL, Desvigne-Nickens P, Sopko G, Rouleau JL (2016-04-21). "Coronary-Artery Bypass Surgery in Patients with Ischemic Cardiomyopathy". N Engl J Med. 374 (16): 1511–20. doi:10.1056/NEJMoa1602001. PMID 27040723.
- ↑ Murphy SP, Ibrahim NE, Januzzi JL (2020-08-04). "Heart Failure With Reduced Ejection Fraction: A Review". JAMA. 324 (5): 488–504. doi:10.1001/jama.2020.10262. PMID 32780858 Check
|pmid=value (help). - ↑ Ryan M, Petrie MC, Kontopantelis E, Dodd M, Tong G, Marquis-Gravel G, Docherty KF, Clayton T, Lansky AJ, Mamas MA, Rouleau JL, Velazquez EJ, Perera D (2025-06-09). "Medical Therapy and Outcomes in REVIVED-BCIS2 and STICHES: An Individual Patient Data Analysis". Eur Heart J. 46 (22): 2052–2062. doi:10.1093/eurheartj/ehaf080. PMID 40048661 Check
|pmid=value (help). - ↑ Tam DY, Dharma C, Rocha R, Farkouh ME, Bhatt DL, Garg P, Gaudino M, Fremes SE (2020-09-08). "Long-Term Survival After Surgical or Percutaneous Revascularization in Patients With Diabetes and Multivessel Coronary Disease". J Am Coll Cardiol. 76 (10): 1153–1163. doi:10.1016/j.jacc.2020.06.069. PMID 32854840 Check
|pmid=value (help). - ↑ Hlatky MA, Boothroyd DB, Bravata DM, Boersma E, Booth J, Brooks MM, Carrié D, Clayton TC, Danchin N, Flather M, Hamm CW, Hueb WA, Kähler J, Kelsey SF, King SB, Kosinski AS, Lopes N, McDonald KM, Rodriguez A, Serruys P, Sigwart U, Stables RH, Owens DK, Pocock SJ (2009-04-04). "Coronary artery bypass surgery compared with percutaneous coronary interventions for multivessel disease: a collaborative analysis of individual patient data from ten randomised trials". Lancet. 373 (9670): 1190–7. doi:10.1016/S0140-6736(09)60552-3. PMID 19303634.
- ↑ Ahn JM, Park DW, Lee CW, Chang M, Cavalcante R, Sotomi Y, Onuma Y, Tenekecioglu E, Han M, Lee PH, Kang SJ, Lee SW, Kim YH, Park SW, Serruys PW, Park SJ (2017). "Comparison of Stenting Versus Bypass Surgery According to the Completeness of Revascularization in Severe Coronary Artery Disease: Patient-Level Pooled Analysis of the SYNTAX, PRECOMBAT, and BEST Trials". JACC Cardiovasc Interv. 10 (14): 1415–1424. doi:10.1016/j.jcin.2017.04.037. PMID 28412459.
- ↑ van Nunen LX, Zimmermann FM, Tonino PA, Barbato E, Baumbach A, Engstrøm T, Klauss V, MacCarthy PA, Manoharan G, Oldroyd KG, Pijls NH, De Bruyne B (2015-11-07). "Fractional flow reserve versus angiography for guidance of PCI in patients with multivessel coronary artery disease (FAME): 5-year follow-up of a randomised controlled trial". Lancet. 386 (10006): 1853–60. doi:10.1016/S0140-6736(15)00057-4. PMID 26466021.
- ↑ Yin F, Zhang Y, Zhang X, Chen Y, Cui X (2024-07-15). "Updated Meta-Analysis of Fractional Flow Reserve Versus Coronary Angiography for Guiding Percutaneous Coronary Intervention". PLoS One. PMID 41066506 Check
|pmid=value (help). - ↑ Stähli BE, Varbella F, Linke A, Schwarz B, Mauri Ferré J, Persson J, Omerovic E, Brugaletta S, Pernow J, Witt N, Huber K, Haude M, Redfors B, Rickli H, Pereira H, Toth GG, Frobert O, Windecker S, Valgimigli M, Mehilli J (2023-10-12). "Timing of Complete Revascularization with Multivessel PCI for Myocardial Infarction". N Engl J Med. 389 (15): 1368–1379. doi:10.1056/NEJMoa2307862. PMID 37781002 Check
|pmid=value (help). - ↑ Henry TD, Tomey MI, Tamis-Holland JE, Thiele H, Rao SV, Menon V, Klein DG, Naka Y, Piña IL, Kapur NK, Keenan J, Baran DA, Ohman EM, Morrow DA (2021-04-13). "Invasive Management of Acute Myocardial Infarction Complicated by Cardiogenic Shock: A Scientific Statement From the American Heart Association". Circulation. 143 (15): e815–e829. doi:10.1161/CIR.0000000000000959. PMID 33762069 Check
|pmid=value (help). - ↑ Ding T, Yuan X, Chen K, Shi J, Cui H, Ren S, Jiang W, Hu S (2023-01-09). "Simultaneous Hybrid Coronary Revascularization vs Conventional Strategies for Multivessel Coronary Artery Disease: A 10-Year Follow-Up". JACC Cardiovasc Interv. 16 (1): 71–83. doi:10.1016/j.jcin.2022.09.040. PMID 36585380 Check
|pmid=value (help). - ↑ Lee JM, Choi KH, Song YB, Lee JY, Lee SJ, Lee SY, Kim SM, Yun KH, Cho JY, Kim CJ, Ahn HS, Nam CW, Yoon HJ, Park YH, Lee WS, Jeong JO, Song PS, Doh JH, Jo SH, Yoon CH, Kang MG, Koh JS, Lee KY, Lim YH, Cho YH, Cho JM, Jang WJ, Chun KJ, Hong D, Park TK, Yang JH, Choi SH, Gwon HC, Hahn JY (2023-05-04). "Intravascular Imaging-Guided or Angiography-Guided Complex PCI". N Engl J Med. 388 (18): 1668–1679. doi:10.1056/NEJMoa2216607. PMID 36876735 Check
|pmid=value (help). - ↑ Lee JM, Kim O, Song YB, Lee JY, Lee SJ, Lee SY, Kim SM, Yun KH, Cho JY, Kim CJ, Ahn HS, Nam CW, Yoon HJ, Park YH, Lee WS, Jeong JO, Song PS, Doh JH, Jo SH, Yoon CH, Kang MG, Koh JS, Lee KY, Lim YH, Cho YH, Cho JM, Jang WJ, Chun KJ, Choi KH, Park TK, Yang JH, Choi SH, Gwon HC, Hahn JY (2026-04-28). "Intravascular Imaging- Vs Angiography-Guided Complex PCI: 5-Year Outcomes From a Randomized Trial". J Am Coll Cardiol. 87 (16): 2099–2113. doi:10.1016/j.jacc.2026.01.035. PMID 41778943 Check
|pmid=value (help).