Long-term outcomes of single-session versus staged strategies for elective multivessel percutaneous coronary intervention

Background Previous studies have suggested that performing multivessel percutaneous coronary intervention (PCI) in a single session yields short- to mid-term outcomes comparable to staging the procedures, in both ST-elevation myocardial infarction and in non–ST-elevation acute coronary syndrome (NSTE-ACS) or chronic coronary syndrome (CCS). However, the long-term outcomes of single-session versus staged multivessel PCI in elective (non-ST-elevation) patients remain unclear. Purpose To assess the association between a single-session vs. staged multivessel PCI strategy and long-term clinical outcomes in patients with NSTE-ACS or CCS undergoing elective multivessel PCI. Methods We analyzed a multicenter PCI registry (Coronary REvascularisation Demonstrating Outcome Study in Kyoto [CREDO-Kyoto] cohort-2 [2005–2007] and cohort-3 [2011–2013]) that enrolled 30,866 consecutive patients undergoing first coronary revascularization. From this pooled cohort, 3,953 patients with multivessel coronary artery disease who underwent elective PCI (for NSTE-ACS or CCS) were identified. Among these, 1,450 patients (36.7%) received single-session multivessel PCI and 2,503 (63.3%) underwent staged multivessel PCI. Baseline clinical and angiographic characteristics were compared between the groups. The primary outcome measure was all-cause death up to 5 years. A 1-year landmark analysis was conducted to evaluate differences in mortality beyond the first year. Results Patients treated with a single-session strategy had less extensive disease at baseline and less complex interventions: the prevalence of three-vessel disease was lower in the single-session group than in the staged group (43% vs. 54%, p<0.0001). Despite less extensive baseline disease in the single-session group, the 5-year all-cause mortality was significantly higher in the single-session group compared to the staged group (18.2% vs. 13.2%; log-rank p<0.0001). In multivariable analysis, single-session PCI remained independently associated with a higher risk of all-cause death (adjusted hazard ratio 1.35, 95% confidence interval 1.14–1.60; p=0.0004). In the 1-year landmark analysis, there was no significant difference in mortality between the two strategies within the first year; however, beyond 1 year, the mortality curves diverged, with the single-session group experiencing a continuously higher mortality rate and an increasing gap in survival compared to the staged group. Conclusions In patients with NSTE-ACS or CCS undergoing elective multivessel PCI, a single-session revascularization strategy was associated with higher 5-year all-cause mortality compared to a staged PCI strategy. Notably, this mortality difference only became apparent after the first year.