Is Angioplasty Able to Become the Gold Standard of Treatment Beyond Bypass Surgery for Patients With Multivessel Coronary Artery Disease? - Therapeutic Strategies for 3-Vessel Coronary Artery Disease: OPCAB vs PCI (PCI-Side) -

Abstract

The optimal strategy of revascularization for multivessel disease has been controversial for a long time. In general, the initial trials 1-5 performed in the 1990s to compare PCI and CABG enrolled patients who had relatively low risk and relatively normal left ventricular function. Study participants primarily had 2-vessel disease that was deemed treatable by either method, and none had serious comorbid conditions. Those trials were performed before widespread use of coronary stents and glycoprotein IIb/IIIa inhibitor. The major findings of these trials are outlined in Table, and are all consistent and reveal no differences in overall survival or rate of Q-wave myocardial infarction (MI) in patients with multivessel disease who were randomly assigned to PCI or CABG. There was a lower rate of repeat revascularization in patients who underwent CABG than in those who had PCI.It appeared that patients with treated diabetes who underwent revascularization had lower mortality with CABG than with stenting, but this was dependent on using a left internal mammary artery graft to the left anterior descending artery. Coronary Stenting vs CABGCurrently, more than 80% of PCI procedures are performed using stents, and some clinical trials have clearly demonstrated the benefits of stents compared with plain ordinary balloon angioplasty (POBA) in regard to acute angiography results, need for emergency CABG, and restenosis rates. 1,6,7 Similarly, there has been concomitant growth in pharmacologic adjunctive therapy of dual antiplatelet therapy of aspirin and thienopyrides. In the Era of Bare Metal Stents (BMS)ARTS Trial The largest of these trials was the Arterial Revascularization Therapies Study (ARTS), 1 which included This article reviews the treatment of patients with multivessel coronary artery disease (CAD). Percutaneous coronary intervention (PCI) has been challenging coronary artery bypass grafting (CABG) as the gold standard of care for patients with multivessel disease; however, the application of PCI to these patients has been mainly limited by restenosis. Up to the beginning of the 2000s, many large-scale, randomized trials addressed this issue by comparing CABG to PCI with balloon angioplasty or bare metal stents in not only Western countries but also in Asian countries. These studies demonstrated similar rates of all-cause death and myocardial infarction in both groups, although the need for revascularization remained significantly lower in the CABG group. PCI with drugeluting stents (DES) is safe and may represent a viable alternative to CABG for selected patients with diabetes and multivessel CAD. Moreover, DES implantation under intravascular ultrasound guidance and with fractional flow reserve might have the potential to influence treatment strategy and reduce both DES thrombosis and repeat revascularization. The evolution of DES and advanced vascular imaging would mean that PCI continues to challenge CABG as treatment of choice for patients who need revascularization for a better prognosis. (Circ J 2010; 74:...

Robot-Assisted Cardiac Surgery

“…12,13) Hybrid revascularization combines minimally invasive coronary artery bypass, such as ThoraCAB and totally endoscopic CABG, with PCI; integrating these two procedures into one therapeutic modality aims to provide patients with the benefits of each successive technique in the least invasive way. The survival benefit of the left IMA for ostial or complex lesions of the LAD has been established.…”

Benefit of Complete Revascularization in Patients With Multivessel Coronary Disease in the Drug-Eluting Stent Era

“…In this regard, PCI vs. CABG for MVD in the current DES era is to be further tested. 20 The superiority of DES itself, in terms of safety, seems to be challenging. Among reports comparing the safety of DES vs. BMS, a few observational studies and their meta-analysis reported even better safety for using DES.…”

Predicting Long-Term Mortality After First Coronary Revascularization - The Kyoto Model -

“…Regarding the issue of individualized treatment selection, a subgroup analysis that pooled individual patient data suggested that CABG might be better for patients with DM and for those aged 65 years or older. 31- 33 That result indicates that a better coronary revascularization strategy is possible in theory if individual risk profiles are taken into account.…”