Completeness of Revascularization as a Determinant of Outcome: A Contemporary Review and Clinical Perspectives

It has been debated whether patients with multivessel coronary artery disease should undergo complete revascularization (CR). The benefit of CR is biologically plausible, and numerous studies and large meta-analyses suggested that CR achievement was associated with a substantial reduction of mortality and future coronary events. In patients with multivessel coronary artery disease, the aim of myocardial revascularization is to minimize residual ischemia. Therefore, CR of all significant coronary lesions has been proposed as the first priority in decision-making for myocardial revascularization between coronary artery bypass grafting and percutaneous coronary intervention (PCI). Reflecting the contemporary practice of ischemia-based revascularization, a physiological/functional approach, such as measurement of fractional flow reserve or instantaneous wave-free ratio, is considered more reasonable and should be encouraged for appropriate CR. In patients who present with acute ST-elevation myocardial infarction, current evidence suggests that an immediate or staged CR strategy might be equivalent or superior to culprit-only revascularization. There is still uncertainty on when and how to perform CR in ST-elevation myocardial infarction patients; comprehensive studies dedicated to this issue are required. Hybrid coronary revascularization includes the advantages of minimally invasive bypass grafting for the left anterior descending artery and PCI for non-left anterior descending arteries and has been proposed as a viable alternative for coronary artery bypass grafting or PCI only for achieving CR. In clinical practice, the extent of revascularization and strategy for CR should be individualized, taking account of different aspects of the patients, lesions, and treating physicians. Collaboration of coronary heart teams would confer balanced decision-making and advanced therapeutic capabilities.