Complex PCI: Complex Characteristics Impact Results

Patients with a bigger number of complex anatomical characteristics that increase PCI complexity have worse results at one-year followup.

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These data come from a large multicenter study (e-Ultimaster) recently published in EuroIntervention.

The more complex the characteristics, the greater the increase in events. 

It is important to see past the obvious anatomical challenges (bifurcations, calcification, multivessel disease, etc.) and keep a wider perspective. A patient is much more than their coronary arteries. Complexity procedure also contributes (atherectomy, hemodynamic support).

PCI complexity is not a binary variable. There is an infinite range of greys in between with a dose/response outcome curve. Each point contributes to complexity and to increased hazard ratio. 

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In this study in particular, the authors define complexity based on factors used by the 2017  European guidelines for dual antiplatelet therapy. These factors give us a general idea, but we still need a standardized definition. 

The analysis included 35839 patients (mean age 64) undergoing coronary PCI between 2014 and 2018 with Ultimaster DES.

Risk characteristics were: multivessel disease, at least three stents, at least three lesions, bifurcations with at least 2 stents, total length covered with stents of 60 mm or more and chronic total occlusion. 27.3% of patients presented at least one risk characteristic but the vast majority presented more than one (73.3%), most frequently multivessel PCI, with 16.3%.

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Patients with more risk characteristics tended to be older, have more comorbidities, and chronic coronary syndrome. 

At one-year followup, target vessel failure rate was significantly higher in patients with at least one risk characteristic vs. patients with no risk characteristics for both the combined end point and its separate components. End points such as cardiac death (HR 1.28; CI 95% 1.05-1.55), target vessel related MI (HR 1.48; CI 95% 1.18-1.86) and clinically driven revascularization (HR 1.42; CI 95% 1.20-1.68) were associated to PCI complexity. 

Increased risk characteristics involve increased adverse events rate which, in addition to the ones mentioned, includes stent thrombosis. 

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Bifurcations increased target vessel failure rate by close to 100% (HR 2.01; 95% CI 1.55-2.62).

Bleeding risk resulted similar in both groups at 30 days, but after a year, patients with complex PCI characteristics had more bleeding events. 

This might be explained because some risk factors are common to both ischemic and bleeding events, such as hypertension, diabetes, kidney failure and old age. 

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Original Title: Impact of coronary lesion complexity in percutaneous coronary intervention: one-year outcomes from the large, multicentre e-Ultimaster registry.

Reference: Mohamed MO et al. EuroIntervention. 2020;16:603-612.

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