Multivessel Disease

Soon after the introduction of coronary artery bypass surgery, the completeness of revascularization became a matter of concern. Several early surgical studies confirmed the belief that better clinical outcomes were obtained when each and every angiographically visible stenosis was bypassed by a distal anastomosis.1,2 Similarly, among patients with multivessel disease treated with percutaneous coronary intervention (PCI), complete revascularization was found to provide a significant advantage over incomplete revascularization in terms of reintervention, myocardial infarction, and death.3,4 However, a careful analysis of surgically treated multivessel disease patients in the Bypass Angioplasty Revascularization Investigation (BARI) trial showed that 1 graft to any system other than the left anterior descending confers no long-term advantage over PCI and may actually be deleterious.5Article see p 2613More recently, the results of large surgical registries supported strategies of reasonably incomplete revascularization.6–8 In addition, the Fractional Flow Reserve Versus Angiography for Multivessel Evaluation (FAME) trial indicated that, in patients with multivessel disease, ≈ one third of angiographically significant stenoses were actually hemodynamically not significant.9 Stenting limited to stenoses with a fractional flow reserve (FFR) value below 0.80 yielded better clinical outcomes than stenting based on treating every visible lesion, introducing the concept of functionally complete rather than anatomically complete revascularization.Several factors contribute to the marked variability in prognostic value of incomplete revascularization reported. First, the definition of incomplete revascularization …