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  • Perspective
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Illusion of revascularization: does anyone achieve optimal revascularization during percutaneous coronary intervention?

Nature Reviews Cardiology (2024)Cite this article

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Abstract

This Perspective article is a form of ‘pastiche’, inspired by the 1993 review by Lincoff and Topol entitled ‘Illusion of reperfusion’, and explores how their concept continues to apply to percutaneous revascularization in patients with coronary artery disease and ischaemia. Just as Lincoff and Topol argued that reperfusion of acute myocardial infarction was facing unresolved obstacles that hampered clinical success in 1993, we propose that challenging issues are similarly jeopardizing the potential benefits of stent-based angioplasty today. By analysing the appropriateness and efficacy of percutaneous coronary intervention (PCI), we emphasize the limitations of relying solely on visual angiographic guidance, which frequently leads to inappropriate stenting and overtreatment in up to one-third of patients and the associated increased risk of periprocedural myocardial infarction. The lack of optimal revascularization observed in half of patients undergoing PCI confers risks such as suboptimal physiology after PCI, residual angina and long-term stent-related events, leaving an estimated 76% of patients with an ‘illusion of revascularization’. These outcomes highlight the need to refine our diagnostic tools by integrating physiological assessments with targeted intracoronary imaging and emerging strategies, such as co-registration systems and angiography-based computational methods enhanced by artificial intelligence, to achieve optimal revascularization outcomes.

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Fig. 1: Rate of PCI overtreatment without FFR guidance.
Fig. 2: Rate of physiologically suboptimal or ischaemic FFR or QFR after PCI.
Fig. 3: Rate of recurrent angina after PCI.
Fig. 4: Anticipated diminishing proportion of patients successively meeting each of the criteria for optimal reperfusion during STEMI or optimal revascularization after PCI.
Fig. 5: Coronary physiology as a continuous marker of cardiovascular risk.
Fig. 6: Physiological patterns of epicardial atherosclerosis.

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Acknowledgements

The authors are supported in part by a Science Foundation Ireland Research Professorship Award (15/RP/2765) to W.W., which supports S.F., D.D. and J.H., and by grants from the Natural Science Foundation of China (no. 82020108015 and 81871460) to S.T. F.M. is supported by Deutsche Gesellschaft für Kardiologie, Deutsche Forschungsgemeinschaft (SFB TRR219, project ID 322900939) and Deutsche Herzstiftung.

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Author notes

  1. These authors contributed equally: Simone Fezzi, Daixin Ding.

Authors and Affiliations

  1. The Lambe Institute for Translational Medicine, the Smart Sensors Laboratory and Curam, University of Galway, Galway, Ireland

    Simone Fezzi, Daixin Ding, Jiayue Huang & William Wijns

  2. Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy

    Simone Fezzi

  3. Department of Cardiology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China

    Daixin Ding

  4. Saarland University Hospital, Internal Medicine III, Cardiology, Angiology, Intensive Care Medicine, Homburg/Saar, Germany

    Felix Mahfoud

  5. Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA

    Felix Mahfoud

  6. University Heart Center Basel, Department of Cardiology, University Basel, Basel, Switzerland

    Felix Mahfoud

  7. Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China

    Jiayue Huang

  8. Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA

    Alexandra J. Lansky

  9. Department of Cardiology, Ren Ji Hospital, School of Medicine, and School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China

    Shengxian Tu

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Contributions

S.F., D.D. and W.W. researched data for the article. S.F., D.D., S.T. and W.W. discussed its content and wrote the manuscript. All the authors reviewed/edited the article before submission.

Corresponding authors

Correspondence to Shengxian Tu or William Wijns.

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Competing interests

F.M. has received scientific support from Ablative Solutions, Medtronic and ReCor Medical and speaker honoraria/consulting fees from Ablative Solutions, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Inari, Medtronic, Merck, ReCor Medical, Servier and Terumo. A.J.L. has received consulting fees from MedAlliance and MicroPort. S.T. is the co-founder of Pulse Medical, and reports research grants and consultancy from Pulse Medical. W.W. reports grants and consulting fees from MicroPort, is a medical adviser for Corrib Core Laboratory and Rede Optimus, and is a co-founder of Argonauts, which is an innovation facilitator. All other authors declare no competing interests.

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Fezzi, S., Ding, D., Mahfoud, F. et al. Illusion of revascularization: does anyone achieve optimal revascularization during percutaneous coronary intervention?. Nat Rev Cardiol (2024). https://doi.org/10.1038/s41569-024-01014-0

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