Drug-eluting stents for interventional revascularization of coronary multivessel disease

The treatment of coronary artery disease has changed over the past 35 years since the introduction of coronary artery bypass surgery in 1968. Percutaneous coronary intervention, introduced in 1977 with balloon angioplasty, was accelerated by the establishment of elective stent placement in 1994, together with the development of suitable antiplatelet regimes. In 2002, DES were made commercially available, following the results of clinical trials in single lesions. A meta-analysis of four randomized clinical trials comparing bare stents to bypass surgery for multivessel disease conducted in the 1990s demonstrate no mortality difference at 1 year. Similar 5-year outcomes have been reported by the ARTS trial. These trials, however, showed that repeat revascularization was much higher in the stent arm, due to restenosis. Various single center (RESEARCH, T-SEARCH) and multicenter (ARTS II) registries have consistently showed a low need for repeat intervention in patients with multivessel disease with the use of DES. Three major trials comparing DES against bypass surgery are ongoing or about to start and will determine the optimum revascularization therapy in multivessel disease. The recently commenced SYNTAX randomized trial will enroll only three-vessel or left main disease, while the upcoming FREEDOM and ongoing CARDia trial will specifically enroll diabetic patients only with multivessel disease. Results for these trials are expected in 2006-2007 at the earliest.