CABG, stents, or hybrid procedures for left main disease?

Coronary artery bypass graft (CABG) surgery, including grafting of the left internal mammary artery (LIMA) to the left anterior descending artery (LAD) with additional vein or IMA grafts to other vessels, remains the standard technique for treatment of three-vessel coronary artery disease in patients with an intermediate or high SYNTAX score. Unprotected left main coronary disease is most often found in association with multivessel disease. In these patients, CABG has long been considered the gold standard for revascularisation. However, the evidence is being challenged by technological and procedural advances in percutaneous coronary intervention. Especially in patients with low to intermediate anatomic complexity of left main disease, PCI can be an effective and durable treatment option. Left main bifurcation lesions, however, remain a challenging subset for PCI due to possible plaque shift and occlusion of a major side branch. While there is general agreement that coronary bypass revascularisation using the LIMA to the LAD provides the best long-term prognostic benefit, a combination of CABG to the LAD and PCI of the remaining lesions, a hybrid approach, takes advantage of the survival benefit of the LIMA to LAD bypass, while minimising invasiveness and lowering morbidity by avoiding median sternotomy, rib retraction, aortic manipulation, and cardiopulmonary bypass. In particular, elderly patients with severe concomitant diseases may benefit from this approach by avoiding CPB.