[Bypass surgery versus percutaneous coronary intervention in patients with diabetes mellitus]

At present, in patients with diabetes mellitus and coronary multivessel disease no fixed general recommendation can be given in favor or to the disadvantage of surgical revascularization or in favor or to the disadvantage of percutaneous coronary intervention (PCI). In cases with an evidence-based indication for coronary revascularization because of clinical symptoms and/or proven ischemia, both therapeutic alternatives of bypass surgery or PCI are electable. The decision, which method of revascularization to prefer, must be based on close analyses of individual risk profile, individual comorbidity, and individual coronary morphology. With correct indication, both therapeutic methods are equivalent regarding the prognostically important combined endpoint of death, nonfatal myocardial infarction, and stroke. For PCI, however, there is a higher probability of restenosis depending on the complexity of lesion morphology, requiring more often repeat interventions or revascularizations. Before deciding in subfavor of or against a surgical or nonsurgical revascularization procedure, the complexity of the coronary artery disease should be analyzed, for example using the SYNTAX Score. In patients with SYNTAX Scores > or = 33 and no contraindications to bypass surgery, a surgical revascularization should be preferred. In the intermediate group with SYNTAX Scores between 23 und 32, the advantages and disadvantages of bypass surgery or PCI, for instance, the increased probability of restenosis with a higher necessity of repeat revascularizations after PCI, should be extensively discussed with the patient. In patients with SYNTAX Scores between 0 and 22, the nonsurgical, interventional therapy using drug-eluting stents (DES) can be recommended as an equivalent alternative to bypass surgery. In meta-analyses of randomized controlled trials and meta-analyses of large registries with PCI in patients with diabetes mellitus, clear advantages of DES in comparison with bare-metal stents (BMS) could be shown. Especially for patients with diabetes mellitus, there is still no clear evidence in favor of or against a special DES type or in favor of or against a special stent covering. Further sufficiently powered randomized controlled trials with hard clinical endpoints comparing bypass surgery with PCI (e.g., FREEDOM trial) and comparing different types of DES in patients with diabetes mellitus and clear PCI indications must be awaited, before further recommendations can be given.