[Coronary angioplasty in subgroups at risk: patients treated with bypass]

Percutaneous coronary intervention represents an established method to obtain revascularization in patients suffering from obstructive coronary artery disease. Despite the predictability of procedural results and the favorable clinical outcome shown in large series, there are still areas in which the clinical benefits of intervention are less impressive and a lot remains to be done to improve both procedural and clinical outcomes. Among these areas, one may well include the subgroup of patients with previous bypass surgery, who have been consistently shown to be affected by a high rate of periprocedural complications as well as late recurrence. The risk profile of these patients is examined under two main perspectives: the burden of more severe baseline clinical conditions (age, ventricular function, severity of coronary disease) and the negative impact of graft atherosclerosis. The basic assumption of this article is that a variable combination of these characteristics identifies subsets with increasing risk of complications and/or recurrence. For this reason, results of percutaneous revascularization in these patients may still represent a technical as well as a clinical challenge. In particular, the long debated relationship between composition of atherosclerotic plaque in saphenous vein graft, distal embolization, periprocedural myocardial damage and early and late adverse events represents a negative sequence that currently available pharmacologic and interventional resources cannot consistently antagonize. Added to this, are the unresolved issues of diffuse degeneration and chronic total occlusion of saphenous vein grafts, in which no therapeutic approach, alone or in combination, has substantially modified the poor outcome of these lesions. The use of glycoprotein IIb/IIIa receptor antagonists is also discussed, in the light of available data derived from large clinical trials, casting doubts on the efficacy of these otherwise essential pharmacologic agents. Lastly, the setting of acute myocardial infarction represents the clinical scenario in which the adverse effects of the combination of clinical and angiographic characteristics are clearly appreciated. Both coronary intervention and cardiac surgery represent fields of rapidly growing knowledge and technology. It is likely that in the near future we will witness major changes in the clinical management of these patients, thanks to the increasing utilization of arterial conduits, the widespread use of local drug delivery, the availability of new percutaneous devices, and the development of integrated pharmacologic and mechanical revascularization strategies.