PCI in the long lesion

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Anum Ijaz M.B.B.S., M.D.[2]

Lesion Assessment

Coronary CT angiography comparison of a focal versus a long (diffuse) coronary lesion, each shown in longitudinal (curved multiplanar reformat) and cross-sectional views. (A1) Longitudinal CCTA of a focal lesion with the plaque length measured at 11.4 mm; (A2) matching axial cross-section showing a short, localized noncalcified/mixed plaque with preserved adjacent lumen. (B1) Longitudinal CCTA of a long lesion with the plaque length measured at 30.2 mm, demonstrating extensive predominantly calcified atherosclerosis extending along the vessel; (B2) matching axial cross-section confirming heavy circumferential calcification and diffuse luminal narrowing.

Overview

A diffuse lesion is defined as a coronary artery lesion of greater than 20 mm in length. It may also be referred to as diffuse disease, extensive lesion or long lesion. Resistance to coronary blood flow in a coronary vessel is not only due to the severity of a focal stenosis, but also to the length of that stenosis. Long lesions that are moderate in nature may therefore cause a significant resistance to flow.

An abnormal fractional flow reserve across a long segment may reflect either a discrete focal pressure drop or a continuous pressure loss along the whole vessel, and these two patterns respond differently to stent implantation. Intracoronary imaging guidance is recommended when performing percutaneous coronary intervention on long lesions. A total stent length exceeding 60 mm classifies the procedure as complex percutaneous coronary intervention and alters antiplatelet planning. Where long or diffuse disease forms part of high-complexity multivessel disease, coronary artery bypass graft surgery is a reasonable alternative to percutaneous coronary intervention.

PCI in The Long Lesion

• A lesion of 20 mm or greater should be managed as a long lesion. A total stent length exceeding 60 mm additionally classifies the procedure as complex percutaneous coronary intervention.
• Hyperaemic pressure pullback should be performed before stent implantation to distinguish focal from diffuse disease, since fractional flow reserve alone does not predict whether the vessel will achieve an optimal physiological result.
• The pullback pressure gradient is a continuous index running from 0 to 1, with values approaching 1 indicating focal disease and values approaching 0 indicating diffuse disease. No single value separates the two patterns, and published series have dichotomised at the median of their own population or by tertile.
• The index has been validated in vessels with a fractional flow reserve of 0.80 or less. Its role where fractional flow reserve exceeds 0.80 is unknown, and it should not be used to guide decisions in that setting.
• A lower pullback pressure gradient identifies a vessel at higher risk of periprocedural myocardial infarction and less likely to achieve an optimal result after stent implantation, and deferral should be considered. Where a single cut-off has been applied, a value below 0.62 has been used to define the diffuse group.
• Pullback-based deferral has not been shown in a randomised trial to improve clinical outcomes and should not override established indications for revascularization.
• A normal post-procedural fractional flow reserve is rarely achieved after stenting long diffuse disease, and residual ischaemia should be anticipated and discussed with the patient before the procedure.
• Functional restenosis is considerably more common than angiographic restenosis after treatment of long diffuse disease. Recurrent symptoms should therefore be assessed physiologically rather than angiographically.

Treatment

• A single stent that is very long should be placed to minimize stent overlap which is associated with greater risk of stent thrombosis.
• If a bare metal stent is placed, it should be remembered that the risk of restenosis proportional to the length of the bare metal stent placed in the segment.
• There some data to suggest that glycoprotein IIbIIIa inhibition is of greater use in longer lesions given the greater extent of vessel injury.
• Drug-eluting stents should be used in preference to bare metal stents in all patients undergoing percutaneous coronary intervention, to prevent restenosis, myocardial infarction and acute stent thrombosis.
• Where one device can cover the lesion and both reference segments, it should be preferred to overlapping stents. Overlap carries higher cardiac mortality and target lesion revascularization, and lengthens fluoroscopy and contrast exposure, irrespective of stent generation.
• Stents up to 48 mm are available and permit single-device treatment of most diffuse lesions, with outcomes comparable to overlapping stents.
• Lesion length is not an indication for glycoprotein IIbIIIa inhibition. These agents should be reserved for bail-out use when no reflow or intraprocedural thrombus occurs.
• Bail-out glycoprotein IIbIIIa inhibition reduces microvascular obstruction on imaging but does not reduce infarct size and increases bleeding, so the decision to use it should be weighed against bleeding risk.
• Where long or diffuse disease forms part of high-complexity multivessel disease, coronary artery bypass graft surgery should be considered in preference to percutaneous coronary intervention.

Intravascular Imaging Guidance

• Intracoronary imaging by intravascular ultrasound or optical coherence tomography should be used to guide percutaneous coronary intervention of every long lesion.
• The same applies in acute coronary syndrome when the lesion is complex.
• Imaging guidance reduces target lesion failure, cardiac death, myocardial infarction, repeat revascularization and stent thrombosis compared with angiography alone.
• Where a stent of 28 mm or longer is required, intravascular ultrasound guidance reduces cardiac death, target lesion myocardial infarction and ischaemia-driven target lesion revascularization, and the benefit is maintained to five years.
• Where a stent of 38 mm or longer is required, imaging guidance reduces target vessel failure and the composite of cardiac death and target vessel myocardial infarction, with benefit sustained beyond five years.
• Intravascular ultrasound and optical coherence tomography are equivalent for guiding percutaneous coronary intervention of complex lesions and either may be used.
• Intravascular ultrasound should be preferred in renal impairment and where the length of the segment makes blood clearance for optical coherence tomography impractical.
• The evidence is not uniformly positive. Optical coherence tomography guidance has produced larger stent dimensions without a reduction in target vessel failure in one large trial, an inconsistency attributed to the inclusion of less complex lesions.
• Imaging should be performed before implantation to measure true lesion length, to size the stent from the distal reference and to identify reference segment disease that would otherwise be left uncovered.
• Imaging should be repeated after implantation, targeting a minimal stent area of 5.5 mm² or greater, or at least 80% of the mean reference lumen area, along the whole stented segment.
• Failure to meet these targets carries increased major adverse cardiac events, stent thrombosis and target vessel revascularization, and should prompt further post-dilatation before the procedure is concluded.
• Adequate expansion at one point does not guarantee adequate expansion along the whole stent; the entire stented length should be interrogated.
• Underexpansion and proximal edge dissection are the imaging findings most strongly associated with subsequent failure and should be corrected before the case is completed.

Lesion Preparation

• Long lesions are frequently calcified, and calcification is the principal cause of stent underexpansion in this setting.
• Intracoronary imaging should be used to define calcium arc, thickness and length before a modification strategy is chosen.
• Balloon-based modification, intravascular lithotripsy or atherectomy should be completed before stent deployment rather than attempted as a rescue after underexpansion.

Drug-Coated Balloon and Hybrid Strategies

• Drug-eluting stent implantation remains the default treatment. A drug-coated balloon-only strategy should not be substituted for stenting in de novo coronary disease.
• Drug-coated balloons carry a higher rate of target lesion revascularization than drug-eluting stents in de novo lesions.
• A hybrid strategy, treating the most severe focal segment with a drug-eluting stent and the remaining diffusely diseased segment with a drug-coated balloon, may be considered to limit total metal burden in lesions of 30 mm or greater, but is supported only by observational data and should not be regarded as established.
• Adequate lesion preparation and an acceptable acute angiographic result are prerequisites for drug-coated balloon use.

Adjunctive Antiplatelet Therapy

• A total stent length exceeding 60 mm defines complex percutaneous coronary intervention and identifies a patient at higher ischaemic risk.
• Prolonged dual antiplatelet therapy was formerly recommended on this basis, but current practice is to maintain potent P2Y12 inhibition and withdraw aspirin early rather than to extend dual antiplatelet therapy.
• In patients who have tolerated dual antiplatelet therapy with ticagrelor, transition to ticagrelor monotherapy is recommended at one month or more after percutaneous coronary intervention.
• Withdrawal of aspirin with continued ticagrelor reduces bleeding without increasing ischaemic events, including in patients whose procedure met complex criteria on the basis of total stent length.
• Whether P2Y12 monotherapy should be continued beyond twelve months in patients with a very long total stent length has not been established.

Step-wise approach for management of long lesions

Step 1: Confirm the lesion and the revascularization modality

• Lesion of 20 mm or greater → manage as a long lesion
• Long or diffuse disease within high-complexity multivessel disease → consider coronary artery bypass graft surgery

Step 2: Define the disease pattern physiologically

• Fractional flow reserve above 0.80 → pullback pressure gradient is not validated; do not use it to guide the decision
• Focal pressure drop on hyperaemic pullback, pullback pressure gradient approaching 1 → proceed
• Continuous pressure loss along the vessel, low pullback pressure gradient → anticipate a suboptimal physiological result and consider deferral

Step 3: Image before implantation

• Intravascular ultrasound or optical coherence tomography to measure true length, size from the distal reference and identify reference segment disease
• Renal impairment or a very long segment → prefer intravascular ultrasound

Step 4: Prepare the lesion

• Severe calcification on imaging → balloon-based modification, intravascular lithotripsy or atherectomy before stent deployment
• No significant calcification → proceed to implantation

Step 5: Implant

• Single long drug-eluting stent covering the lesion and both reference segments
• Avoid overlap where a single device of up to 48 mm will suffice

Step 6: Optimise under imaging

• Minimal stent area of 5.5 mm² or greater, or at least 80% of the mean reference lumen area, throughout → conclude
• Underexpansion, proximal edge dissection or uncovered reference disease → post-dilate or extend coverage

Step 7: Set antiplatelet strategy

• Total stent length exceeding 60 mm → complex percutaneous coronary intervention
• Tolerated dual antiplatelet therapy with ticagrelor → ticagrelor monotherapy from one month

Complications

Long lesions are associated with a greater plaque burden and as such are likewise associated with a greater risk of no reflow. Longer lesions are also associated with an increased risk of side branch occlusion.

• A diffuse rather than focal disease pattern on pressure pullback, indicated by a lower pullback pressure gradient, identifies patients at higher risk of periprocedural myocardial infarction.
• Bail-out glycoprotein IIbIIIa inhibition for no reflow improves microvascular obstruction on imaging but does not limit infarct size and increases bleeding.
• Side branch occlusion can be predicted before the procedure using the RESOLVE score, derived from quantitative coronary angiography, or the V-RESOLVE score, derived from visual estimation of six bifurcation characteristics.
• Side branch occlusion carries a substantially higher rate of periprocedural myocardial infarction and in-hospital major adverse cardiac events, and wire protection should be considered for branches identified as high risk.
• The number of jailed side branches rises with the length of the stented segment, so the risk applies cumulatively across a long lesion.
• Longer stent length is itself an independent predictor of cardiac death and target vessel myocardial infarction.

2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization (DO NOT EDIT)

Stent Selection (DO NOT EDIT)

Class 1

"1. In patients undergoing PCI, DES should be used in preference to BMS to prevent restenosis, MI, or acute stent thrombosis. (Level of Evidence: A)"

Intravascular Imaging Guidance (DO NOT EDIT)

Class 2a

"1. In patients undergoing coronary stent implantation, IVUS can be useful for procedural guidance, particularly in cases of left main or complex coronary artery stenting, to reduce ischemic events. (Level of Evidence: B-R)"

"2. In patients undergoing coronary stent implantation, OCT is a reasonable alternative to IVUS for procedural guidance, except in ostial left main disease. (Level of Evidence: B-R)"

Revascularization Modality in Diffuse Disease (DO NOT EDIT)

Class 2a

"1. In patients who require revascularization for multivessel CAD with complex or diffuse CAD (e.g., SYNTAX score >33), it is reasonable to choose CABG over PCI to confer a survival advantage. (Level of Evidence: B-R)"

2024 ESC Guidelines for the Management of Chronic Coronary Syndromes (DO NOT EDIT)

Intracoronary Imaging (DO NOT EDIT)

Class I

"1. Intracoronary imaging guidance by IVUS or OCT is recommended for performing PCI on anatomically complex lesions, in particular left main stem, true bifurcations and long lesions. (Level of Evidence: A)"