Percutaneous Revascularization in End-Stage Kidney Disease (ESKD) Patients With Non-culprit Coronary Stenosis: A Strategy Beyond Fractional Flow Reserve.

Complete myocardial revascularization, targeting both culprit and non-culprit coronary stenoses, is recommended by current guidelines in acute myocardial infarction (AMI) management, either during the index percutaneous coronary intervention (PCI) procedure or within 45 days, depending on the clinical context. However, in patients with chronic kidney disease (CKD), particularly end-stage kidney disease (ESKD), fractional flow reserve (FFR) presents unique challenges. Altered coronary physiology in CKD, such as arterial stiffness and microcirculatory dysfunction, affects FFR accuracy, complicating revascularization decisions. Recent evidence from large clinical trials has demonstrated no significant benefit of FFR-guided complete revascularization over culprit-only PCI in AMI patients. Current guidelines recommend complete revascularization but caution against sole reliance on FFR in CKD patients, suggesting alternative imaging techniques for improved risk assessment. Complete revascularization can be performed either during the index PCI procedure or staged during the same hospital admission, as data suggest better outcomes when revascularization is completed during the admission rather than delayed. Further research is needed to refine strategies for optimal outcomes in this high-risk population.