Revascularization in the high-risk patient: multivessel disease

Area of Science:

• Cardiology
• Interventional Cardiology
• Cardiac Surgery

Background:

• Multi-vessel coronary artery disease (CAD) treatment traditionally favors coronary artery bypass grafting (CABG) over percutaneous coronary intervention (PCI).
• Restenosis was a major limitation for PCI in multi-vessel CAD, impacting repeat revascularization rates.
• Advancements in both PCI (drug-eluting stents - DES) and CABG (minimally invasive techniques, arterial grafting) have evolved treatment paradigms.

Purpose of the Study:

• To review the current treatment strategies for patients with multi-vessel coronary artery disease.
• To compare the efficacy and outcomes of PCI with DES versus CABG in contemporary practice.
• To inform clinical decision-making based on individual patient risk and anatomy pending definitive trial results.

Main Methods:

• Review of large-scale randomized trials comparing CABG and PCI (balloon angioplasty, bare-metal stents) from the pre-DES era.
• Analysis of recent trials and ongoing studies evaluating PCI with DES against CABG.
• Consideration of advancements in surgical techniques and stent technology.

Main Results:

• Pre-DES trials showed similar death/myocardial infarction rates but higher revascularization needs with PCI compared to CABG.
• DES have significantly reduced restenosis and repeat revascularization rates after PCI.
• Contemporary CABG techniques have also improved perioperative outcomes and graft utilization.

Conclusions:

• Previous trial results comparing PCI and CABG are outdated due to advancements like DES and improved surgical methods.
• Current evidence comparing contemporary PCI with DES and CABG remains inconclusive.
• Individualized treatment selection based on patient-specific factors is crucial until new trial data becomes available.