Ischemic and bleeding events after complex versus non-complex PCI; a systematic review and meta-analysis

Objective To evaluate the impact of complex percutaneous coronary intervention (PCI) on clinical outcomes in patients undergoing myocardial revascularization. Design and data sources: Systematic review and meta-analysis. Embase, MEDLINE and PUBMED-not-medline databases from inception through December 2024. Study selection: We included all studies investigating the prognostic role of complex PCI in patients undergoing PCI. Data extraction and synthesis: Two reviewers extracted data and assessed the risk of bias. The primary analysis was conducted using a random-effects model within a Bayesian framework. All principal analyses were based on adjusted risk estimates, with hazard ratios (adjusted-HR). Secondary analysis included, separately, studies providing unadjusted risk estimates. Outcomes of interest: The primary outcomes of interest were myocardial infarction and major bleeding. Additional outcomes included all-cause death, cardiovascular death, stent thrombosis, target-vessel (or target-lesion) revascularization, and stroke. Results A total of 290,039 participants, of whom 94,633 (33%) met complex-PCI criteria, was included. Patients undergoing complex vs. non-complex PCI had an increased risk of myocardial infarction (adjusted-HR 1.71, 95%CrI 1.49 to 1.96) and major bleeding (adjusted-HR 1.24, 95%CI 1.14 to 1.35). Compared with patients undergoing non-complex PCI, those treated with complex PCI had an increased risk of all-cause death (adjusted-HR 1.21, 95%CrI 1.12 to 1.32), stent thrombosis (adjusted-HR 1.71, 95%CrI 1.45 to 2.04), cardiovascular death (adjusted-HR 1.29, 95%CrI 1.15 to 1.46), target-vessel (or target-lesion) revascularization (adjusted-HR 1.99, 95%CrI 1.58 to 2.49) and stroke (adjusted-HR 1.21, 95%CrI 1.03 to 1.42). The posterior probability that complex PCI was associated with a higher risk than non-complex PCI exceeded 99% for all outcomes. These findings were consistent across studies that reporting unadjusted risk estimates. Conclusions Patients undergoing PCI have a dual-hazard risk of ischemic and bleeding events compared with patients undergoing non-complex PCI.Resume outcomesFor image description, please refer to the figure legend and surrounding text.