Key result
Immediate complete revascularization resulted in similar 2-year MACE rates compared to staged revascularization in patients with unresolved culprit lesion complications (10.6% vs 17.2%; HR 0.58; P=0.27).
Why the study?
The optimal timing of complete revascularization (immediate vs staged) in ACS and multivessel disease remains debated, and it was unknown whether unresolved culprit-lesion-related complications influence outcomes.
Does immediate complete revascularization reduce major adverse cardiovascular events compared to staged complete revascularization in ACS patients with multivessel disease and unresolved index PCI complications?
RCT (n=1,487)
randomized
Does immediate complete revascularization reduce major adverse cardiovascular events compared to staged complete revascularization in ACS patients with multivessel disease and unresolved index PCI complications?
Immediate complete revascularization yields comparable 2-year clinical outcomes to a staged approach in ACS patients with multivessel disease, even when unresolved culprit lesion complications are present during the index PCI.
Comparable MACE rates with ICR versus SCR should not yet change practice; leaves open need for RCTs in ACS multivessel disease with unresolved complications.
BACKGROUND: In patients with acute coronary syndrome (ACS) and multivessel disease (MVD), complete revascularization (CR) improves clinical outcomes compared with culprit-only percutaneous coronary intervention (PCI). However, the optimal timing of CR, immediate (ICR) versus staged (SCR), remains debated. AIMS: This post hoc analysis of the BIOVASC trial aimed to evaluate whether unresolved culprit-lesion-related complications influence outcomes of ICR compared with SCR and to identify predictors of procedural complications. METHODS: Among 1525 patients enrolled in BIOVASC, 1487 index coronary angiographies were analyzed. Coronary complications related to culprit lesion PCI were classified and assessed for resolution status. Clinical outcomes were evaluated at 2-year follow-up according to randomized treatment strategy (ICR vs. SCR). Logistic regression was used to identify independent predictors of complications. RESULTS: Culprit-lesion-related complications occurred in 153 of 1487 procedures (10.3%), with 125 (81.7%) unresolved at the end of the index procedure. The most frequent complications were side branch occlusion or slow flow and distal slow reflow. Among patients with unresolved complications, the 2-year rate of major adverse cardiovascular events (MACE: death, myocardial infarction, unplanned revascularization, or stroke) was similar between ICR and SCR (10.6% vs. 17.2%; HR 0.58, 95% CI 0.22-1.52; p = 0.27). Independent predictors of procedural complications were complex culprit lesion morphology (class B2/C) (OR 1.68, 95% CI 1.07-2.63; p = 0.023) and STEMI presentation (OR 1.45, 95% CI 1.00-2.11; p = 0.049). CONCLUSIONS: In patients with unresolved culprit lesion complications during index PCI, ICR showed comparable 2-year outcomes to the staged approach. Complex lesion morphology and STEMI presentation independently predicted procedural complications. These findings suggest that ICR remains a safe and viable strategy in hemodynamically stable patients, even in the presence of procedural challenges.
No takes yet. Share an insight, caveat, or question.
Gabrielli et al. (2026) conducted an RCT in Acute coronary syndrome (ACS) and multivessel disease (MVD) (n=1,487). Immediate complete revascularization (ICR) vs. Staged complete revascularization (SCR) was evaluated on Major adverse cardiovascular events (MACE: death, myocardial infarction, unplanned revascularization, or stroke) (HR 0.58, 95% CI 0.22-1.52, p=0.27). Immediate complete revascularization resulted in similar 2-year MACE rates compared to staged revascularization in patients with unresolved culprit lesion complications (10.6% vs 17.2%; HR 0.58; P=0.27).
Synapse has enriched 5 closely related papers on similar clinical questions. Consider them for comparative context: