PCI Of Lesions Research Articles

TCT-816 Comparing FFR-Guided PCI and Conservative Management for Nonculprit Lesions in STEMI Patients With Multivessel Disease: A Systematic Review and Meta-Analysis

TCT-816 Comparing FFR-Guided PCI and Conservative Management for Nonculprit Lesions in STEMI Patients With Multivessel Disease: A Systematic Review and Meta-Analysis

Predictive utility of residual SYNTAX score for clinical outcomes after successful primary percutaneous coronary intervention

Background In patients presenting with ST-segment elevation myocardial infarction (STEMI), the prevalence of having concomitant severe non-culprit lesion(s) is ≥40%. While timely primary PCI (pPCI) for the culprit lesion is the standard practice, management of the non-culprit lesions remains unsettled. Results This prospective multi-center observational study recruited 492 acute STEMI patients who underwent successful pPCI for the culprit lesion. Culprit-only versus complementary non-culprit lesion(s) PCI (either immediate or staged during the same hospital stay) was according to the operator’s discretion. Clinical, echocardiographic, and angiographic data were collected and tabulated. The residual SYNTAX score (rSS) was completed by the time of discharge considering the residual lesions after all in-hospital revascularization procedures. Through a minimum follow-up of 12 months, older age, presentation with heart failure Killip class ≥ II, lower estimated glomerular filtration rate (eGFR) on admission, lower left ventricular ejection fraction (LVEF), and higher rSS by discharge were significantly associated with recurrent MACE. In multivariate regression analysis, Killip class ≥ II, LVEF, and rSS were found to be independent predictors for recurrent MACE. In the Receiver Operating Characteristics curve, an rSS of >8 had a sensitivity of 70.1%, and specificity of 75.3% to predict 1-year MACE. Conclusions Residual syntax score proved to be an independent predictor for recurrent MACE through the subsequent year post STEMI. Patients with rSS >8 seem to be at the highest risk for adverse events and are likely to be the most deserving for completing revascularization to reduce the disease burden.

Contrast-enhanced excimer laser stepwise approach during PCI for resistant coronary lesions.

The treatment of resistant coronary lesions (RCL) is a great challenge for interventional cardiologists. The excimer laser coronary atherectomy (ELCA) is a plaque modification tool based on a main mechanism of photomechanical effect leading to mechanical disruption of the plaque. Contrast dye injection during laser delivery has demonstrated to enhance its power. To evaluate the effectiveness and safety of the contrast-enhanced ELCA by a stepwise approach in the treatment of RCLs. We retrospectively examined consecutive patients undergoing contrast-enhanced ELCA-assisted PCI between 2018 and 2021 at two Italian sites. RCLs were defined as novo or in-stent undilatable/uncrossable with conventional balloons (SC/NC balloon). The primary endpoint was ELCA technical success defined as the laser catheter crossing the entire length of the target lesion established by angiographic evidence of the catheter tip in the artery distal to the stenosis. We enrolled 114 patients who underwent contrast-enhanced ELCA-assisted PCI: 58% of the patients had acute coronary syndrome while the left anterior descending artery was the target vessel in 42.1% of cases. The target lesion was most commonly in-stent (56.2%). The 0.9 mm ELCA catheter tip was employed in 89.5% of cases. The most used frequency/fluency profile was 70/70 (39.5%). The use of contrast-enhanced ELCA was associated with high technical, procedural, and clinical success rates (97.4%, 93.7%, and 90.1%, respectively). The contrast-enhanced ELCA seems to be a safe and effective treatment option for the management of both de novo and in-stent-resistant coronary lesions.

Mechanism of Stent Failure in Patients With Eruptive Calcified Nodule Treated With Rotational Atherectomy

BackgroundPercutaneous coronary intervention (PCI) for lesions with eruptive calcified nodules (CNs) is associated with worse outcomes compared with that for other calcified lesions. We aimed to clarify the relationship between eruptive CNs at index PCI, optical coherence tomography (OCT) findings at the 8-month follow-up, and clinical outcomes using serial OCT. MethodsThis retrospective observational study used data from a prospective, single-centre registry. We conducted consecutive PCI for calcified lesions requiring rotational atherectomy (RA) with OCT guidance. We categorized 51 patients (54 lesions) into those with (16 patients [16 lesions]) and without eruptive CNs (35 patients [38 lesions]). ResultsPost-PCI, stent expansion was comparable between the 2 groups, and CN-like protrusion was found in 75% of lesions with eruptive CNs. Follow-up OCT at 8 months revealed in-stent CNs in 54% of treated eruptive CN lesions, whereas lesions without eruptive CNs lacked in-stent CNs. Multivariate linear regression analysis demonstrated that eruptive CN was associated with maximum neointimal tissue (NIT) thickness (regression coefficient 0.303; 95% confidence interval, 0.057-0.549; P = 0.02). Consequently, patients with eruptive CNs exhibited a higher clinically driven target lesion revascularization (TLR) rate than did those without at 1 year (31.3% vs 2.9%, P = 0.009) and 5 years (43.8% vs 11.4%, P = 0.02). TLR primarily occurred in lesions with maximum eruptive CN arc angles > 180°. ConclusionsFollowing RA treatment with acceptable stent expansion, eruptive CNs before PCI correlated with greater NIT formation with in-stent CNs, resulting in a higher TLR rate, particularly in lesions with maximum eruptive CN arc angles exceeding 180°.

Is There a Role for Physiology-Guided PCI of Nonculprit Lesions in Patients With STEMI?

Is There a Role for Physiology-Guided PCI of Nonculprit Lesions in Patients With STEMI?

Impact of Using a Scoring Balloon for Main Branch Predilatation on the Incidence of Side Branch Compromise in Bifurcation Lesion PCI

Impact of Using a Scoring Balloon for Main Branch Predilatation on the Incidence of Side Branch Compromise in Bifurcation Lesion PCI

A predictors for 10-year mortality and clinical events in patients with chronic coronary total occlusion lesion

Abstract Background Despite advances in cardiovascular intervention techniques and devices, the treatment of patients with chronic coronary total occlusion CTO lesions is challenging yet. We evaluated predictors of 10-year mortality and clinical events in patients with CTO lesions in this study. Methods This study is a single-center, prospective, all-comer registry designed to reflect "real world" practice since 2001. Of a total of 1,672 consecutive patients were diagnosed with CTO lesions by coronary angiogram. The primary endpoints were all-cause death or major adverse cerebral, and cardiac events (MACCE) defined as the composite of all-cause death, myocardial infarction (MI), any coronary revascularization, and stroke up to 10 years. We derived for final results, from survival analysis by Kaplan-Meier and Cox-proportional regression analysis. Results In this study, males were 1,255 (75.1%), and the mean age was 65.2±10.9. Also, a total of 660 patients had received a successful PCI for CTO lesions at enrollment. A total of 267 patients was heart failure. Ten years of clinical follow, MACCE occurs in 407 cases (56.6%), all-cause death in 152 cases (18.5%), cardiac death in 87 cases (9.9%), myocardial infarction (MI) in 54 cases (7.7%), any revascularization of 251 cases (30.7%), and stroke of 41 cases (6.3%) by Kaplan-Meier analysis. In a multiple Cox-proportional regression analysis, a prior myocardial infarction, reduced LV ejection fraction less than 50%, chronic kidney disease, multi-vessel disease had increased a risk of MACCE and the use of statin, and aspirin had reduced a risk of MACCE. Also, an aging, prior MI, reduced LV ejection fraction less than 40%, and multi-vessel disease had increased a risk of all-cause death and the use of statin, and renin-angiotensin system inhibitors, nitrates, statin, and aspirin had reduced a risk of risk of all-cause death. However, PCI for CTO lesions could not reduce both of MACCE and all-cause death. Conclusions The study found that a prior myocardial infarction, reduced LV ejection fraction, chronic kidney disease, and multi-vessel disease were associated with an increased risk of MACCE, while the use of statins and aspirin reduced the risk of MACCE. Furthermore, PCI for CTO lesions did not reduce the incidence of MACCE or all-cause death. These findings highlight the need for further research and development of more effective treatment strategies for patients with CTO lesions.

3-dimensional ct versus angiography guided pci for ostial rca lesions

Abstract Background Geographical stent-ostium mismatch is an important predictor of target lesion failure (TLF) after PCI of an aorto-ostial right coronary artery (RCA) lesion. Purpose We hypothesize that a pre-procedural 3-dimensional coronary CT angiography (3DCT) to determine the optimal C-arm angle of the X-ray system with the most accurate visualization of the aorto-ostial angle could allow optimal stent implantation at the level of the ostium and avoid excessive use of radiation and contrast. Methods This is a single centre trial randomizing 30 patients with an indication for non-emergent PCI of an ostial RCA lesion between 3DCT (intervention group) versus angiography guided strategy (control group). While in the control group the C-arm angle was at the operators’ discretion, in the intervention group the angle was determined based on a pre-PCI CT scan with 3D reconstruction using Materialise Mimics Innovation Suite software. A pre- and post-PCI IVUS is performed in all patients and analyzed by a blinded core lab. The primary endpoint is absence of geographical mismatch on IVUS defined as full stent coverage of the ostium and maximal aortic protrusion equal or less than 3mm. Secondary, we also aim to investigate whether a pre-procedural 3DCT may reduce procedural radiation, contrast use, may predict IVUS parameters (minimal luminal area (MLA), calcification), stent sizing and may promote stent expansion. Finally, MACE rate is evaluated at 1 month. Results The full patient dataset (n=30) including primary and all secondary endpoints will be available for presentation at the ESC congress. Currently, 27 patients were randomized. An interim analysis shows the following findings. There is significant patient heterogeneity considering the optimal angle for stent implantation, underscoring the potential benefit for individualized pre-procedural CT planning. In general, more extreme LAO angles were used in patients randomized to the intervention group (picture 1). While the stent was implanted in optimal position in 13/13 (100%) patients randomized to the intervention group, geographical stent mismatch was present in 5/14 (36%) patients randomized to the control group (interim p-value 0.07) (picture 2). The number of cine acquisitions performed before stent implantation (1±1.87 vs. 3.5±0.60; p=0.0007), the amount of contrast used (60±24.5 vs. 114±37.8 mL; p=0.0002), radiation dose (209 [186,315] vs. 497 [411,678] mGy; p=0.01) and procedure time (30 [20,38] vs. 50 [39,66] min; p=0.005) were significantly lower in patients randomized to the intervention group. There was a highly significant correlation between the calcium arc determined by CT and IVUS (R² = 0.84). No MACE occurred at 1 month. Conclusion We showed that pre-procedural CT planning for PCI of aorto-ostial RCA lesions allowed for optimal stent positioning while reducing procedure time, contrast and radiation use.Picture 1Picture 2

Timing of Complete Revascularization with Multivessel PCI for Myocardial Infarction

BackgroundIn patients with ST-segment elevation myocardial infarction (STEMI) with multivessel coronary artery disease, the time at which complete revascularization of nonculprit lesions should be performed remains unknown.MethodsWe performed an international, open-label, randomized, noninferiority trial at 37 sites in Europe. Patients in a hemodynamically stable condition who had STEMI and multivessel coronary artery disease were randomly assigned to undergo immediate multivessel percutaneous coronary intervention (PCI; immediate group) or PCI of the culprit lesion followed by staged multivessel PCI of nonculprit lesions within 19 to 45 days after the index procedure (staged group). The primary end point was a composite of death from any cause, nonfatal myocardial infarction, stroke, unplanned ischemia-driven revascularization, or hospitalization for heart failure at 1 year after randomization. The percentages of patients with a primary or secondary end-point event are provided as Kaplan–Meier estimates at 6 months and at 1 year.ResultsWe assigned 418 patients to undergo immediate multivessel PCI and 422 to undergo staged multivessel PCI. A primary end-point event occurred in 35 patients (8.5%) in the immediate group as compared with 68 patients (16.3%) in the staged group (risk ratio, 0.52; 95% confidence interval, 0.38 to 0.72; P<0.001 for noninferiority and P<0.001 for superiority). Nonfatal myocardial infarction and unplanned ischemia-driven revascularization occurred in 8 patients (2.0%) and 17 patients (4.1%), respectively, in the immediate group and in 22 patients (5.3%) and 39 patients (9.3%), respectively, in the staged group. The risk of death from any cause, the risk of stroke, and the risk of hospitalization for heart failure appeared to be similar in the two groups. A total of 104 patients in the immediate group and 145 patients in the staged group had a serious adverse event.ConclusionsAmong patients in hemodynamically stable condition with STEMI and multivessel coronary artery disease, immediate multivessel PCI was noninferior to staged multivessel PCI with respect to the risk of death from any cause, nonfatal myocardial infarction, stroke, unplanned ischemia-driven revascularization, or hospitalization for heart failure at 1 year. (Supported by Boston Scientific; MULTISTARS AMI ClinicalTrials.gov number, NCT03135275.)

MEDICAL MANAGEMENT OF BROKEN GUIDEWIRE: CASE REPORT

Bifurcation lesions were once indicating surgery but not anymore, now they will follow the same principles for revascularization of non-bifurcation lesions. However, PCI of bifurcation lesions can be world widely challenging due to anatomic characteristics of each lesion. Guidewire fracture is known to be a rare complication of percutaneous coronary intervention. The consequences however might be deadly, and its management is still debated until further guidelines. The aim of this article is to raise the difficulties of the interventional care of the LAD/Diagonal lesions.

PCI of bystander coronary artery lesions should be performed before TAVI: pros and cons.

PCI of bystander coronary artery lesions should be performed before TAVI: pros and cons.

Management of Densely Calcified Coronary Lesions using OPN–NC Balloon and Shockwave Intravascular Lithotripsy Procedure

Background: Calcified coronary lesions are challenging to the interventional cardiologists to manage. Debulking the calcified lesions with Rotablation is a well known strategy. Shockwave intravascular lithotripsy (IVL) is the newer novel therapeutic procedure found to be very effective in PCI of calcified lesions. Aims and Objectives: To assess the clinical utility of Shockwave IVL in densly calcified coronary lesions. Materials and Methods: Four patients underwent PCI with Shockwave IVL for densly calcified lesions between Febraury and March of 2020 and were followed up clinically in our centre. Results: All patients are doing well clinically without any coronary events. Conclusion: Shockwave IVL is safe and accepted modality of debulking the densly calcified coronary lesions and prepare the bed for optimal stent deployment.

Effective Factors on Successful PCI of CTO Lesions

Effective Factors on Successful PCI of CTO Lesions

Percutaneous coronary intervention for true bifurcation lesions: a single-center experience including the setting of acute coronary syndromes

Abstract Funding Acknowledgements Type of funding sources: None. Background Percutaneous coronary intervention (PCI) for true coronary bifurcation lesions is challenging. Purpose To describe procedural and clinical outcomes of true bifurcation PCI. Methods Single-center retrospective study of consecutive patients (pts) submitted to PCI for true bifurcation lesions (06/2018-06/2020). MACE comprised death, myocardial infarction (MI), stroke, restenosis and reintervention. Results During the study period, 1678 PCI were performed, of which 7% were for true bifurcation lesions (Medina x,x,1). 118 pts (mean age 66.4 ± 11.0 years; 74.6% male; 32.2% diabetic; mean left ventricular ejection fraction 49.8 ± 8.4%) were included. Most pts (64.7%) were treated in the setting of an acute coronary syndrome (ACS): 26.7% ST-elevation MI, 31.9% non-ST-elevation MI, 6.0% unstable angina. 35.3% were treated for a chronic coronary syndrome. 24.8% of pts presented with 3-vessel disease and 11.1% had a left main (LM) lesion. The most frequently diseased main branch was the left anterior descending artery: 21.2% (68), followed by the left circumflex: 17.8% (21), right coronary artery: 12.7% (15) and LM: 11.9% (14). In terms of bifurcation classification, lesions were mainly Medina 1,1,1 (71.2%), followed by 0,1,1 (13.6%); 1,0,1 (9.2%) and 0,0,1 (5.9%). PCI was mainly performed via radial artery (73.7%). Mean number of stents: 1.4 ± 0.6. Lesions were predominantly treated with single stenting technique (80.3%). Double-stenting was used in 23 (19.7%) pts: TAP was the most used technique (10), followed by culotte (3), crush (2), double kissing crush (2) and T-stent (1). Proximal optimization technique and kissing balloon inflation were performed in 38.1% and 44.9% of cases, respectively. Rotational atherectomy was used in 10.4%. Ventricular support devices were used in 3 pts (1 Impella, 2 intra-aortic balloon pump). Intracoronary imaging was used in 13 pts: intravascular ultrasound (IVUS) and optical coherence tomography (OCT) in 8 and 5 pts, respectively; its use was more frequent in cases of LM PCI (p=.002). OCT was associated with higher contrast doses (350 vs 224 ml, p&amp;lt;.001), with no increase in acute kidney injury incidence (p=.413). Fluoroscopic time (p=.684) and radiation dose (p=.916) did not differ. Side branch occlusion occurred in 5 pts and iatrogenic coronary dissection in 7 pts. At a mean follow-up time of 17.3 ± 8.1 months, MACE and mortality rates were 13.3% and 6.9%. MACE occurred more frequently in pts with LM lesion (p&amp;lt;.001) and less often in cases where complete revascularization was achieved (p=.006). Conclusions True bifurcations represented a relatively small percentage of PCI lesions and were mainly performed in ACS setting. In line with literature, single stenting was the most used technique. MACE rate was globally low and was decreased by complete revascularization. Still, LM bifurcation PCI was associated with increased MACE.

OCT-guided left-main PCI, a retrospective single-center analysis

Abstract Funding Acknowledgements Type of funding sources: None. Background It is known that PCI is associated with non-optimal stent implantation utilizing angiography for only left main lesions as well as for bifurcation lesions and is characterised by a high risk of adverse long-term effects. The use of OCT for the left main stent makes it easier to enhance the effective implantation of stents and enhance the results of patients. Methods A single-center randomised study was performed to demonstrate the benefit of stent implantation under OCT control in the left main bifurcation lesions compared to standard implantation under angiographic control. The follow-up period was 1 year, and the study included 68 patients with 1:1 randomization. The final composite points were: cardiac death, ischaemia, or myocardial infarction. All patients were elective, with moderate to high-functional class of angina pectoris. PCI was done using one or two stents, using OCT or without OCT to perform kissing dilation and proximal optimization technique. Results As a result of the data review of 68 patients with or without OCT using PCI of left main bifurcation lesions, the primary endpoint parameters in the non-OCT group were 17.8% and 6% for the OCT group. In 43.1 % of cases, a single-stent technique was used rather than a two-stent when using OCT. In the OCT group, additional stent optimisation is 40% more common. In 96.7 % of cases, a 9-month follow-up in the OCT group showed complete or partial endothelization of the stent struts, allowing earlier termination of DAPT, which is critical in patients at high risk for significant bleeding. Conclusions The perioperative results of PCI for left main bifurcation can be improved by the use of OCT using regulated factors for optimal stent implantation. As a result, in patients with atrial fibrillation and a high risk of painful bleeding, the long-term effects of treatment are increased , the time to take DAPT is decreased and the number of implantable stents is decreased, which is significant.

Transcatheter closure of ventricular septal rupture with prolonged support of intra-aortic balloon pump after primary PCI: a case report

BackgroundVentricular septal rupture (VSR) is a rare but severe complication of acute myocardial infarction (AMI). For such cases, surgical repair is recommended by major guidelines, but not always possible for such cases.Case presentationA 72-year-old man presented to the emergency room. ECG showed the ST-segment was elevated by 2–3 mm in lead II, III, and aVF, with Q-waves. Coronary angiography (CAG) showed multi-vessel disease with a total occlusion of the right coronary artery (RCA) and severe stenosis of the left anterior descending artery (LAD). A diagnosis of acute inferior myocardial infarction was made. VSR occurred immediately after percutaneous coronary intervention (a 2.5 × 20 mm drug-eluting stent implanted in RCA), and the patient developed cardiogenic shock. An intra-aortic balloon pump (IABP) was used to stabilize the hemodynamics. Transthoracic echocardiography (TTE) revealed an 11.4-mm left-to-right shunt in the interventricular septum. An attempt was made to reduce the IABP augmentation ratio for weaning on day 12 but failed. Transcatheter closure was conducted using a 24-mm double-umbrella occluder on day 28. The patient was weaned from IABP on day 31 and underwent secondary PCI for LAD lesions on day 35. The patient was discharged on day 41. Upon the last follow-up 6 years later, CAG and TTE revealed no in-stent restenosis, no left-to-right shunt, and 51% left ventricular ejection fraction.ConclusionsProlonged implementation of IABP can be a viable option to allow deferred closure of VSR in AMI patients, and transcatheter closure may be considered as a second choice for the selected senior and vulnerable patients, but the risk is still high.

“Balloon boost” imaging: An underutilised “simple” strategy in calcific lesion PCI

“Balloon boost” imaging: An underutilised “simple” strategy in calcific lesion PCI

Impact of wall shear stress affected by anatomical difference between acute and chronic coronary syndrome in patients with LAD proximal disease

Abstract Recent hemodynamic studies have demonstrated that progression of coronary atherosclerosis occurs at low wall share-stress site, whereas plaque rupture frequently occurs at high share stress site. It is well recognized that wall shear stress is relatively low along the outer walls of the bifurcation. We investigated consecutive 140 patients (77 with acute coronary syndrome (ACS) and 63 with chronic coronary syndrome (CCS) performed PCI for LAD proximal lesions (AHA seg.6) from January 2016 to December 2019. In CCS group, entry criteria included stenosis of at least 90% in the LAD proximal lesion or at least 70% in the LAD proximal lesion and objective evidence of myocardial ischemia (inducible ischemia with either exercise or pharmacologic vasodilator stress or with pressure wire). Exclusion criteria were patients with maintenance dialysis, chronic total occlusion lesions, in-stent restenosis, and clinically diagnosed unstable angina without troponin I elevation. We measured the distance from LMT distal carina to the culprit site (Distance) and plaque location (Location) with intravascular ultrasound and angle between LMT and LAD with cardiovascular angiography analysis system (CAAS) (Angle). The two groups were generally well balanced with regard to baseline clinical characteristics. The mean (±SD) age of the patients was 69.0±11.8 years, and 75% were men. Medication at baseline was also similar between two groups except higher prevalence of statin prescription in CCS group. The Distance was shorter and Angle was steeper in CCS group than in ACS group. The number of patients with Angle less than 150 degrees and with Location in the lateral wall side was much more in CCS group. In this study, plaques in CCS were frequently observed at low shear stress site, whereas those in ACS at high shear stress site. Plaque progression in CCS may be associated with low wall shear stress, and high shear stress may play key role in plaque rupture in ACS. This anatomical difference can partly explain the different mechanisms of onset between of ACS and CCS. Funding Acknowledgement Type of funding sources: None. Anatomical differenceCharacteristics and results

Timing of Nonculprit Percutaneous Coronary Intervention after ST-Elevation Myocardial Infarction

Introduction: Complete revascularization of ST-elevation myocardial infarction (STEMI) patients with multivessel disease (MVD) has recently shown to reduce risk of adverse cardiovascular events, including cardiovascular death. Optimal timing of revascularization of nonculprit lesions remains controversial. We aimed to measure cardiac outcomes related to duration between primary percutaneous coronary intervention (pPCI) of the culprit lesion and staged PCI (sPCI) of nonculprit lesions. Methods: From a prospectively collected consecutive registry of 3,002 patients treated for STEMI by pPCI, 1,555 patients with MVD requiring sPCI were identified. Patients were placed into quartiles of duration to sPCI: 0–7 days (Q1), 7–22 days (Q2), 22–42 days (Q3), >42 days (Q4), excluding those who had complete revascularization at the index event. Major adverse cardiac events (MACEs) included all-cause mortality, myocardial infarction, target vessel revascularization, and coronary artery bypass surgery. Cox regression and propensity score matching were performed correcting for confounding factors. Results: The average age at presentation was 65.7 ± 11.5 years. 333 were female (21.4%). Mean time between pPCI and sPCI was 28.3 days (±24.8). Rates of MACE were Q1 - 16.5%, Q2 - 21.2%, Q3 - 25.8%, and Q4 - 30.1% (log-rank <0.001). Following regression analysis, sPCI remained an independent risk factor for MACE (hazard ratio [HR] = 1.226 [95% confidence interval {CI}: 1.129–1.331, p < 0.001]). There was no association between the time interval up to sPCI with all-cause death (HR = 1.022 [95% CI: 0.925–1.129, p = 0.671]). Conclusions: Patients with MVD are at increased risk of experiencing MACE after revascularization of nonculprit vessels with increasing time delay between pPCI and sPCI.

New Paradigm of Complete Revascularization in Acute Coronary Syndrome with Multivessel Coronary Artery Disease: Is it Reasonable in Clinical Practice?

Coronary artery disease is the leading cause of illness and death in older adults. Around 40% to 50% of patients with ST-segment elevation myocardial infarction (STEMI) have multiple coronary artery disease. Multiple vessel coronary disease has been shown to improve cardiac outcomes and survival in patients who have undergone complete revascularization (CR) versus patients who have undergone only incomplete revascularization (ICR). When coronary angiography and PCI of the source of the infarction are performed on patients with STEMI, the risk of adverse cardiac death or myocardial infarction is significantly reduced. Additional research is needed to determine the efficacy of PCI of non-critical lesions. However, following procedures such as CABG or PCI, these procedures may be impossible to perform due to a variety of personal, anatomical, technical, and logistical barriers. In this review, we discussed about benefit of complete revascularization in patient acute coronary syndrome (ACS) with multivessel disease and which patient can be performed aggressive revascularization to achieved CR in clinical practice.