Volume 9 No 2 2021 Fix.indd
International Journal of Integrated Health Sciences (IIJHS) 89
vessel. Approximately 40% - 65% patients who
admit to hospital with STEMI have multi-vessel
disease. Multi-vessel disease is a combination
of culprit lesion and one or more significant
stenosis (≥50% stenosis) non-culprit lesions on
invasive coronary angiography.3 Percutaneous
Coronary Intervention (PCI) has contributed
in improving prognosis patients with STEMI.
Therapy strategy of patients with STEMI
multi-vessel disease caused dilemma as there
are vary strategies.3 Culprit-only PCI strategy
has low contrast volume and complications,
but associated with increased risk of repeated
revascularization. Complete revascularization
strategy has improved prognosis and
Culprit-Only Versus Complete Revascularization in STEMI Multi-Vessel
Disease: A Case Report
Abstract
Objective: To revisit data and highlight management of STEMI multi-
vessel disease and explore culprit-only versus multi-vessel PCI and
optimal timing to achieve complete revascularization.
Methods: A 67 years old male with chest pain at rest 2 hours before
admission with a history of smoking one pack of cigarette everyday,
was presented to the hospital. Physical examination was within normal
limit with normal hemodynamically; however, elevated cardiac troponin
was identified. Electrocardiogram showed STEMI anteroseptal wall
with ischemic inferior wall, leading toSTEMI anteroseptal wall, Killip I
diagnosis. Primary PCI was performed and multi-vessel disease was found.
A complete revascularization single-staged procedure was performed due
to his persistent chest pain. PCI of these coronary stenoses is beneficial
to reduce risk of cardiac death and recurrent infarction. However, some
issues related to PCI of non-culprit coronary arteries lesion and optimal
timing to do complete revascularization is still a dilemma.
Results: Related to data from some trials, e.g PRAMI, CvLPRIT, DANAM-
3-PRIMULTI, COMPARE-ACUTE, COMPLETE, and some meta-analyses,
showed benefit and safety of routine PCI of non-culprit lesions as a
preventive strategy to reduce morbidity and mortality. Data showed
reduce future morbidity and mortality in this setting. Meanwhile, the
optimal timing of complete revascularization is still a matter of debate,
although some data showed benefit of index procedural PCI.
Conclusion: PCI of non-culprit lesions of myocardial infarction is
consistently beneficial over culprit-only revascularization in patients
with STEMI multi-vessel disease, despite the debate on the optimum
timing for complete revascularization in this setting.
Keywords: Complete revascularization, multivessel disease,
percutaneous coronary intervention, STEMI
Received:
December 25, 2020
Accepted:
September 27, 2021
Case Report
Mega Amanda Putri, Achmad Fauzi Yahya, Triwedya Indra Dewi
Department of Cardiology and Vascular Medicine, Faculty of Medicine Universitas Padjajaran-Dr. Hasan
Sadikin General Hospital Bandung, Indonesia
pISSN: 2302-1381;
eISSN: 2338-4506;
http://doi.org/10.15850/
ijihs.v9n2.2249
IJIHS. 2021;9(2):89–94
Correspondence:
Triwedya Indra Dewi,
Department of Cardiology and Vascular Medicine,
Faculty of Medicine Universitas Padjajaran/Dr. Hasan
Sadikin General Hospital Bandung, Indonesia
e-mail: adeindradewi@gmail.com
Introduction
ST-segment elevation myocardial infarction
is a myocardial cell death due to prolonged
ischemia.1 Incidence of STEMI was 58 per
100.000 populations annually.2 In patients
with STEMI, sometimes atherosclerosis is not
limited to single lesion, but involves multi-
90 International Journal of Integrated Health Sciences (IIJHS)
decreased risk of revascularization procedure
and future morbidity.3 Meanwhile, safety
concerns including prolong procedure which
results in contrast overload and radiation
needed to be noticed.3 This case report
and literature study will be interesting
and informative to discuss a management
perspective, especially in management of
STEMI multi-vessel disease in decision of
culprit-only or complete revascularization
and also timing in this particular patients.
Case
A 67 years old male was admitted to hospital
with chest pain at rest 2 hours before
admission. Patient had history of smoking one
pack of cigarette per day. There was no history
of dyspnoea, palpitation, syncope or near
syncope. Hemodynamic was within normal
limit and with normal physical findings.
Laboratory results showed elevated
cardiac troponin, others were within normal
limits. Electrocardiogram showed STEMI
anteroseptal wall with ischemic inferior wall
(Fig. 1). Trans-thoracal echocardiography
showed normal all chambers, reduced left
ventricle systolic function (LVEF 44% Biplane),
with severe hypokinetic anteroseptal wall to
apical, hypokinetic anterior, and anteroseptal
mid to apical. All these findings led to diagnosis
of STEMI anteroseptal wall, Killip I.
OCT guided primary PCI was performed
through access right radial artery with
Diagnosed Cathtere JR 3.5 6 Fr and Guide
Catheter BL 3.5 6 Fr with contrast iohexol.
Coronary angiography showed normal
Left Main (LM) coronary artery; acute total
occlusion with haziness at proximal portion
of Left Anterior Descending (LAD) coronary
artery; diffuse stenosis at mid distal and critical
stenosis at distal of Left Circumflex (LCx)
coronary artery; and normal Right Coronary
Artery (RCA). Intervention was performed
to LAD lesion using Wire Runthrough
Intermediate (Terumo, Japan) conveyed
to distal LAD and Wire Runthough Floppy
(Terumo, Japan) was placed on Diagonal 1
branch. Thrombosuction was done at LAD
and showed TIMI flow 2. Predilation from mid
to osteal LAD was performed using Sprinter
Legend balloon 2.5 x 20 mm (Medtronic,
Mexico) inflated to 8 atm and Sprinter Legend
modified jailed balloon 2.5 x 15 mm (Medtronic,
Mexico) inflated to 10 atm on osteal Diagonal
1. Provisional stenting was performed using
DES Xience Prime 3.0 x 38 mm (Abbott, USA)
placed on mid to osteal LAD. OCT post stenting
showed distal reference diameter 3.0 mm and
under expansion with white thrombus (Fig.
2). Proximal Optimalization Technique (POT)
was carried out proximally with a Sprinter
Legend balloon 3.5 x 15 mm (Medtronic,
Mexico) inflated to 10 atm. OCT post dilation
showed good apposition and expansion with
tissue protrusion at mid stent, MSA 6.4 mm2
without stent edge dissection.
During procedure patient experienced chest
pain with normal hemodynamic and operator
decided to perform another intervention at
LCx non-culprit lesion using Wire Runthrough
Floppy (Terumo, Japan) placed at distal Obtuse
Marginal and Wire Pilot 50 (Abbott, USA) at
Table 1 Randomized Controlled Trials Comparing Revascularization Strategies in Patients
with Multivessel STEMI. 8-11
Study Sample Strategy Non-Culprit Lesions Mace Endpoints
PRAMI 465 Culprit-only
VS
complete
revascularization PCI
% diameter stenosis
≥ 50%
22.9% vs 9.0%
(p<0.001) at 23
months
CvLPRIT 296 Culprit-only vs complete
revascularization index
or staged PCI
% diameter stenosis
> 70% in 1 view or
> 50% in 2 views
21.2% vs 10.0%
(p=0.0009) at 12
months
DANAMI-3-
PRIMULTI
627 Culprit-only vs complete
revascularization with
staged PCI
% diameter stenosis
> 50% with FFR ≤
0.80
22.0% vs 13.0%
(p=0.004) at 27
months
COMPARE-
ACUTE
885 Culprit-only vs complete
revascularization index
or staged PCI
% diameter stenosis
≥ 50% with FFR
≤0.80
20.5% vs 7.8%
(p<0.001) at 1 year
FFR=Fractional Flow Reserve
Culprit-Only Versus Complete Revascularization in STEMI Multi-Vessel Disease: A Case Report
International Journal of Integrated Health Sciences (IIJHS) 91
distal LCx. Predilation was carried out using
Ryujin Plus balloon 1.5 x 15 mm (Terumo,
Japan), Sprinter Legend balloon 2.0 x 12 mm
(Medtronic, Mexico), and Sprinter Legend
balloon 2.5 x 20 mm (Medtronic, Mexico) at
distal to proximal LCx. Stenting was performed
at proximal to distal LCx using Xience Prime
2.5 x 38 mm (Abbott, USA). Contrast injection
showed TIMI flow 2 with thrombus (Fig. 3).
After PCI, patient did not experience any chest
pain and treated with Eptifitabatide for 24
hours after procedure. Operator decided to
evaluate angiography on the 5th day.
Coronary angiography evaluation showed
normal LM; LAD showed stent patent in situ
with 50% stenosis at distal LAD; LCx showed
stent patent in situ; Normal RCA. There was
no thrombus, dissection, or residual stenosis,
with TIMI flow 3. Patient was discharged on
the 9th day without any episode of chest pain
or complication. Informed consent was signed
by patient himself allowing data publication.
Discussion
Current guidelines STEMI recommends PCI
as a preference treatment strategy.4 PCI
was beneficial to reduce the risk of future
morbidity and mortality.5 Despite this benefits,
there are some dilemmatic and controversial
issues related to its benefit for non-culprit
lesion and optimal timing.6 Recent myocardial
revascularization guideline recommends
to achieve complete revascularization in
cases with cardiogenic shock with presence
of multiple critical stenosis, highly unstable
lesions which angiographic signs of thrombi or
rupture of the lesion, or evidence of persistent
ischemia despite angioplasty of the affected
Table 2 Risks and Benefits of Single-Staged Procedure vs Multi-Staged Procedure18
Single-staged Procedure Multi-staged Procedure
Favorable
Preventing of recurrent ischemia /
infarction
Better assessment of non-culprit
lesion and the risks
Decreasing length of hospital stay Using non-invasing testing to
non-culprit lesion
Non Favorable Longer procedure and higher contrast volume and radiation
Additional cost to hospital stays
and procedure
Poor assessment of benefit in non-
culprit lesion
Late staged PCI may not be
beneficial
Table 3 Factors Affecting Timing of Non-Culprit PCI20
Factors favoring index procedure Factors favoring staged procedure
Ongoing chest pain
Infarct artery required short time and contrast
Unstable non-culprit lesion with large area of
myocardium at risk
Simple PCI of non-culprit lesion
Patient preference
Stable symptoms
Chronic kidney disease
Prolonged and complex procedure to open non-
culprit lesion
Complex lesion in non-culprit lesion
Patient preference
Fig. 1 Electrocardiogram Showed STEMI Anteroseptal Wall, Ischemic Inferior Wall
Mega Amanda Putri, Achmad Fauzi Yahya, et al
92 International Journal of Integrated Health Sciences (IIJHS)
artery.7
Trials and meta-analyses demonstrated
conflicting results about beneficial of PCI
in non-culprit lesion. Four multicenter
randomized controlled clinical trials studied
strategies in management of STEMI multi-
vessel disease, such as PRAMI, CvLPRIT,
DANAMI-3-PRIMULTI, and COMPARE-ACUTE.
These RCTs showed a significant reduction in
cardiovascular death, recurrent MI, and repeat
revascularization associated with complete
revascularization strategy (Table 1).8,9,10,11
Despite these supportive results, there
were some limitations of these RCTs as
patients had low-risk features in inclusion
criteria and sample sizes. Therefore, statistical
power to detect differences events of death
or myocardial infarction was low. COMPLETE
trial was conducted to resolve previous trials
limitation, with total of 3,900 patients treated
with DES and optimal medical therapy. Result
showed primary outcome of cardiovascular
death and myocardial infarction at 3 years was
lower in complete revascularization group
compared to culprit-only group. Complete
revascularization was associated with
decreased need of repeated revascularization
and in mortality and subsequent myocardial
infarction in STEMI multi-vessel disease.12,13
Meta-analysis between 2002 to 2019 was
performed with 10 RCTs and 7030 patients.
This meta-analysis showed benefit of routine
Fig. 2 OCT Post Stenting Showed Distal Reference Diameter 3.0 mm and Under Expansion
with White Thrombus
Fig. 3 Coronary Angiography Before and After Stent Deployment, (A) LCx before steting,
(B) LAD before stenting, (C) LCx after stenting, (D) LAD after stenting
Culprit-Only Versus Complete Revascularization in STEMI Multi-Vessel Disease: A Case Report
International Journal of Integrated Health Sciences (IIJHS) 93
non culprit-lesion PCI as a preventive
strategy that reduce subsequent myocardial
infarction and improve survival.14 In order
to conclude results of these trials and meta-
analyses, ESC guidelines supports complete
revascularization strategy as Class IIa
recommendation, and ACC/AHA guidelines
as Class IIb recommendation.15,16 These
guidelines allow staged revascularization of
non-culprit lesions. In our patient, operator
found STEMI multi-vessel disease and decided
to do complete revascularization.
Dilemmatic strategy in patients with
STEMI multi-vessel disease was slightly
resolved using previous data which showed
complete revascularization was more
superior than culprit-only revascularization
in reducing future morbidity and mortality.
Meanwhile, optimal timing of this strategy
remains debatable. Potential options included
performing complete revascularization
index procedural/single-staged or elective
procedural/multi-staged during in hospital
stay or after discharge. Large meta-analysis
by Zhenwei Li et al. showed multi-staged
revascularization had lower incidence of
MACE, all-cause death and/or myocardial
infarction. It also stated that single-staged
procedure complete revascularization was
associated with greater mortality risk.17
CvLPRIT trial showed in hospital stay complete
revascularization of non-culprit lesion,
resulted in improvement of clinical outcomes
compared to culprit-only lesion. Potential
risks and benefits of the two strategies are
summarized in Table 2.18 Network meta-
analysis by Pieter et al.19 using 4 prospective
and 14 retrospective studies between 1985
to 2010 and 40,280 patients successfully
identified patients who underwent multi-
staged PCI had lower rates of all-cause
mortality, TIMI major bleeding, and also less
MACE. Overall, mentioned meta-analyses and
studies suggested multi-staged procedure
as better option compared to single-staged
procedure.
Another meta-analysis including 11
RCTs stated that single-stage complete
revascularization was safe. This strategy had
significantly greater LVEF compared to multi-
stage complete revascularization and reduced
hospitalization days and medical costs. Despite
its benefits, single-stage procedure associated
with longer time and larger contrast volumes
and radiation, and increased rates of contrast-
induced nephropathy (CIN) and procedural
complication. There are some factors affecting
operator in choosing whether complete
revascularization index procedural or staging
(Table 3).20 In our patient, operator decided
to do single-staged procedure due to patient’s
complained ongoing chest pain.
Our case was comprehensively managed by
using intracoronary imaging to help operator
identify culprit and non-culprit lesion better.
This study is lacking ability to identify
non-culprit lesion using non-invasive stress
imaging, particularly in STEMI multi-vessel
disease. FFR is necessary to identify which
lesion is responsible for patient’s symptoms,
meanwhile in this patient PCI was not guided
by FFR.
Complete revascularization in STEMI
multi-vessel disease should be considered
when feasible and applicable. The decision of
strategy using strategy index procedural or
elective procedural is based on individually
factors condition. Best timing of non-culprit
complete revascularization in this setting still
remains dilemmatic and debatable, therefore
further research is needed. It could understand
better that complete revascularization is the
best management in patient with STEMI multi-
vessel disease.
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Culprit-Only Versus Complete Revascularization in STEMI Multi-Vessel Disease: A Case Report