European Journal of Cardiovascular Medicine

Coronary artery disease (CAD) continues to be a major public health concern globally and is the leading cause of morbidity and mortality in India. According to the India Heart Watch study, India accounts for more than 60% of the global CAD burden, with a steep rise observed among urban and semi-urban populations [1]. What is particularly concerning is that CAD affects Indian patients at a much younger age compared to Western populations, often presenting with more diffuse and complex coronary involvement [2].

Multiple contributory factors including urbanization, sedentary lifestyle, tobacco use, dietary changes, and a genetic predisposition to insulin resistance and dyslipidemia have led to a surge in atherosclerotic cardiovascular disease [3–5]. Moreover, the clinical manifestation of CAD in Indians tends to be more aggressive, with higher rates of triple vessel disease, left main involvement, and multi-segmental stenosis. As a result, the interventional management of CAD in India often requires more extensive revascularization strategies [6,7].

Percutaneous coronary intervention (PCI) has emerged as the cornerstone of treatment for symptomatic and high-risk CAD. The evolution of PCI from balloon angioplasty to the widespread use of drug-eluting stents (DES) has significantly improved outcomes and reduced the need for coronary artery bypass grafting (CABG) [9-11]. However, the increasing use of PCI in patients with complex, long-segment, calcified, and bifurcation lesions has led to a growing population of patients who receive three or more stents during the index procedure [12,13].

While the placement of multiple stents may facilitate complete revascularization, especially in patients with diffuse atherosclerosis, concerns regarding increased metal burden, overlapping segments, stent thrombosis, restenosis, and periprocedural complications persist [14–16]. The long-term safety and efficacy of placing multiple stents in a single or multiple vessels during the same procedure remain topics of active investigation. Prior studies suggest mixed outcomes, with some showing increased procedural success but others indicating higher restenosis and revascularization rates [17–19].

Data from Western countries have shown acceptable results with the use of ≥3 stents; however, Indian data on this subset remain scarce. Regional variations in disease presentation, healthcare infrastructure, operator expertise, and adherence to secondary prevention make it essential to study this issue in the local context [20]. The few available Indian registries often do not report procedural outcomes stratified by the number of stents used, thereby limiting comparative understanding [21,22].

In this context, we aimed to evaluate the Clinico-demographic characteristics, angiographic profiles, and procedural outcomes of patients undergoing PCI with three or more stents during the index procedure at a tertiary care center in western India. This study attempts to fill the knowledge gap by providing real-world evidence on short-term safety and efficacy, with a particular focus on complications, target lesion revascularization, and adverse cardiac events during a 3-month follow-up.

This was a MixedCohort Study conducted over a period of 12 months in the Department of Cardiology, MDM Hospital, Dr. S.N. Medical College, Jodhpur. Data was collected from Cathlab records and from patients admitted from June 2024 to June 2025 in Department of Cardiology, MDM Hospital, Jodhpur. The study included a total of 134 adult patients (age >18 years) who underwent PCI with the implantation of three or more coronary stents during a single index procedure. Patients with a prior history of coronary artery bypass graft surgery (CABG) were excluded from the study. All patients included had significant coronary artery disease as defined by ≥70% stenosis in major epicardial vessels or ≥50% in the left main coronary artery (LMCA), as demonstrated by coronary angiography.

Patient enrolment for the prospective arm was carried out after obtaining written informed consent. Clinical evaluation included detailed history-taking and physical examination. Risk factors such as smoking, hypertension, diabetes mellitus, dyslipidaemia, family history of CAD, and obesity were documented. Diagnosis of hypertension and diabetes mellitus was based on standard guidelines from JNC 8[26] and the American Diabetes Association[27] respectively.

All patients underwent standard pre-procedural evaluation including electrocardiogram (ECG), echocardiography, renal function tests, and cardiac biomarkers. Coronary angiography was performed using standard technique via radial or femoral access. The angiographic findings were analyzed for vessel involvement, lesion morphology, and complexity using the American College of Cardiology/American Heart Association (ACC/AHA) classification.

PCI procedures were carried out under standard aseptic precautions using drug-eluting stents (DES). The number, size, and location of stents used were recorded. Procedural details including vascular access, lesion site, adjunctive device use (e.g., intravascular ultrasound, rotablation), and periprocedural pharmacotherapy were also documented. Procedural success was defined as TIMI 3 flow and no immediate complications.

Patients were monitored for in-hospital complications including peri-procedural myocardial infarction, stent thrombosis, coronary dissection, and death. Post-discharge follow-up was conducted at three months either through hospital visits or telephonic interviews to assess for major adverse cardiac events (MACE), including cardiac death, angina recurrence, myocardial infarction, target lesion revascularization (TLR), and heart failure.

Data were collected using a structured proforma and entered into a master chart. Statistical analysis was performed using SPSS version 25.0. Descriptive statistics were expressed as mean ± standard deviation for continuous variables and as percentages for categorical variables. Chi-square test was applied for testing associations between categorical variables. A p-value of less than 0.05 was considered statistically significant.

Out of 134 patients, 99 (74%) were male and 35 (26%) were female. Most patients (77%) were between the ages of 41 and 70 years. Smoking was present in 50 patients (37%), significantly more among males (p<0.0001). Hypertension was noted in 34% and diabetes in 36% of patients. Dyslipidemia and obesity were observed in 22% and 37% of cases respectively. A family history of CAD was noted in 31% of the cohort.

TABLE 1. DEMOGRAPHIC  PROFILE OF PATIENTS: -

Values are presented as Number (%)

Regarding clinical presentation, chronic stable angina (34%) was the most common, followed by inferior wall MI (22%),anterior wall myocardial infarction (20%), NSTEMI (14%), unstable angina (8%), and lateral wall MI (1%). Table 1. Shows these demographic and clinical profile of patients. In terms of angiographic findings, triple vessel disease (TVD) was seen in 62 patients (46%), double vessel disease (DVD) in 45 (34%), and single vessel disease (SVD) in 11 (8%).Involvement of the left main coronary artery (LMCA) with TVD was present in 10 patients (7%). Table 3. Shows angiographic findings of patients. Lesion morphology analysis showed that type B lesions were most common (43%), followed by type A (37%) and type C (20%). Table 2. Show lesion type in different vessels of these patients.

TABLE 2. LESION TYPES CLASSIFICATION: -

Values are presented as Number (%).

TABLE 3. ANGIOGRAPHIC PROFILE OF PATIENTS:  -

Values are presented as Number (%)

During interventional procedure vascular access was achieved by RRA route in 111 patients and RFA route in 23 patients. In 123 patients 3 stents were used, out of which, in 50 patients they were used in single vessel and in remaining 73 patients they were used in multiple vessels. 4 stents were used in total of 11 patients, in 2 of them they wereused in single vessel and in 9 patients they were used in multiple vessels. Non cutting type of balloon (134) were used most frequently followed by scoring (5), cutting and DEB in 2 patients each. Procedural outcomes were highly favourable with 100% success achieving TIMI 3 flow in all 134 patients. Additional procedures in the form of Rotablation, FFR, Bifurcation, TPI, Thrombosuction were done in 6, 2, 17, 3,1 respectively. Table 4. Shows these findings.

Table 4. Procedural details

The most common lesion morphology was discrete lesions (26%), followed by diffuse (13%), concentric (11%), and tubular (15%) types. Bifurcation lesions constituted 9%, predominantly involving the LAD (13%) and LCx (14%). Ostial lesions were noted in 10% of cases, frequently affecting the LMCA (38%) and ramus (38%). Chronic total occlusions (CTO) accounted for 5% of lesions, mainly in LAD and RCA. Calcific (3%) and thrombotic (7%) lesions were less common. In-stent restenosis (ISR) was observed in only 1% of lesions.

TABLE 5. LESION CHARACTERISTIC CLASSIFICATION: -

Values are presented as Number (%)

There were no in-hospital deaths, Q-wave or non-Q-wave myocardial infarctions, stent thrombosis, or emergency CABG procedures. At 3-month follow-up, two deaths were recorded (1.49%), and angina recurrence was reported in 12 patients (8.96%), slow/no flow was seen in 14(10.45%) of the patients, and abrupt vessel closure, dissection and bradycardia was seen in 2(1.49%), 3(2.24%),3(2.24%) respectively. No cases of myocardial infarction, target lesion revascularization (TLR), or stent thrombosis were observed during the follow-up period.

TABLE 6. PROCEDURAL OUTCOME AND COMPLICATIONS:-

The present study demonstrates that PCI using three or more stents can be performed safely in selected patients with complex CAD, showing excellent short-term outcomes. The demographic trend toward a predominantly male population with high incidence of risk factors like smoking, hypertension, and diabetes aligns with existing literature on the Indian CAD burden. Similar trends have been reported in the CREATE registry and other regional studies[12,20].

Our findings show that triple vessel disease and complex lesion types (particularly Type B and C lesions) are not uncommon in Indian PCI candidates. The absence of in-hospital complications and low 3-month MACE rates underscore the procedural safety and early benefit of multi-stent PCI. Prior studies have raised concerns about increased metal burden and higher restenosis rates in such cases, but our cohort did not show early stent thrombosis or need for revascularization[19,21].

The lack of target lesion revascularization or myocardial infarction at 3-month follow-up indicates effective lesion preparation and procedural execution. However, the short follow-up limits conclusions on long-term outcomes like late stent thrombosis or restenosis[25].

A limitation of the study is the absence of a control group (e.g., <3 stents or CABG) and advanced risk prediction analysis. The use of SYNTAX scores[23,24], intravascular imaging, or newer-generation DES was not analyzed due to data constraints. Furthermore, while thestudy is prospective, the designation “mixed-design” has been removed for clarity, since no qualitative or retrospective arm exists.

Despite these limitations, the study adds to the scarce Indian data on high-burden PCI procedures and supports the feasibility of multi-stent PCI in real-world tertiary settings. Larger multi-center studies with extended follow-up and cost-analysis would strengthen the evidence base.

In patients with complex coronary artery disease, PCI with three or more stents during a single index procedure is associated with favourable short-term clinical and angiographic outcomes, including low complication and mortality rates. The results suggest that such an approach is both feasible and safe in the short term, though long-term surveillance and larger comparative studies are essential to validate these findings further and assess cost-effectiveness.

Conflict of interest: None

ACKNOWLEDGEMENTS: We would like to express our deepest gratitude to all the study participants whose work made this study possible.

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