In selected patients with multivessel coronary disease, PTCA and CABG as initial treatments resulted in equivalent improvement in angina after one year. However, in order to achieve similar clinical outcomes, the patients treated with PTCA were more likely to require further interventions and antianginal drugs, whereas the patients treated with CABG were more likely to sustain an acute myocardial infarction at the time of the procedure.

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Excimer laser angioplasty for in-stent restenosis was associated with a high incidence of recurrent restenosis in this group of patients, suggesting that this technique is unlikely to reduce recurrent in-stent restenosis and that other approaches are necessary.

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Although several randomized trials have been performed to compare the outcomes of percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass surgery (CABG) in patients with multivessel disease, there is little data available on angiographic follow-up results. The present substudy of the German angioplasty versus bypass surgery investigation (GABI Trial) compares the angiographic revascularization status in these two cases 6 months after treatment. Follow-up angiograms were available in 102 CABG patients and 117 PTCA patients. Although the protocol excluded patients with total occlusion, on follow-up 6 months after treatment we found total occlusion of 94 native arteries (36.9%) in the CABG group and of six arteries (2.5%) in the PTCA group (P < 0.001). The rate of occluded native vessels did not correlate significantly with the severity of the lesion before bypass surgery. In the CABG group 31 bypass grafts (12.2%) were found to be occluded at the 6 month follow-up examination (29/225 vein grafts [12.9%]; 2/30 mammary artery grafts [6.7%]). The main pathway, defined as the nutrient vessel (native vessel or bypass graft) providing the least resistance to blood flow, was narrowed by a lesion with a diameter stenosis of 70-100% for 36 target lesions (14.1%) in the CABG group and 39 target lesions (16.2%) in the PTCA group (P, ns). However, the prevalence of moderately severe lesions with a 50-69% diameter reduction of the main pathway was significantly greater in the PTCA group (44 lesions, 18.3%) than in the CABG group (19 lesions, 7.5%, P < 0.01). Thus, 6 months after randomized allocation to PTCA or CABG, we found comparable rates of high-grade lesions in the main pathways of both treatment groups. Whereas moderately severe lesions of the main pathway were predominantly seen in the PTCA group, there was marked disease progression to total occlusion in the native circulation after bypass grafting.

The restenosis rate after stenting of lesions in aortocoronary venous bypass grafts still has to be considered unsatisfactorily high. We investigated a new stent design characterized by an expandable polytetrafluorethylene (PTFE) membrane in between two layers of struts. Five consecutive male patients (age 70 +/- 6 years) were followed prospectively who presented with at least two de novo lesions in different grafts 13 +/- 3 years after bypass surgery. A total of 11 lesions were treated located in grafts anastomosed to the circumflex (n = 3), to the LAD (n = 7), and to the right coronary artery (n = 1). Within the same procedure, every patient received membrane-covered stents (n = 6) and conventional stents (n = 5) in either of their lesions. All patients underwent successful interventions. The minimal luminal diameter increased from 1.0 +/- 0.5 to 2.9 +/- 0.6 mm in lesions treated by the membrane-covered stents and from 0.8 +/- 0.4 to 2.4 +/- 0.7 mm in the lesions treated by conventional stents. During follow-up, four out of five patients required angioplasty for in-stent restenosis of lesions covered by a conventional stent, whereas no patient underwent revascularization for a lesion treated by a membrane-covered device. The mean minimal luminal diameter of lesions covered by a conventional stent decreased by 42% to 1.4 +/- 0.6 mm; the mean minimal luminal diameter of the lesions treated by a stent graft declined by 9% to 2.8 +/- 0.6 mm (P < 0.05). This series of intraindividual comparisons suggests that membrane-covered stents may have the power to reduce in-stent restenosis in obstructed aortocoronary venous bypass grafts.

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