Comparison of Immediate Versus Staged Complete Revascularization in Patients With Index PCI Coronary Complications: A Study on Clinical Outcomes and Predictors of 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.