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[PTCA or bypass surgery in multi-vessel coronary disease? Viewpoint of the surgeon]
1Universitätsklinik für Thorax-, Herz- und Gefässchirurgie, Inselspital Bern.
Insights
Percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG) show similar perioperative mortality for multivessel coronary disease. However, PTCA has higher restenosis rates and requires more repeat procedures than CABG.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiac Surgery
Background:
- Randomized studies compare percutaneous transluminal coronary angioplasty (PTCA) with coronary artery bypass grafting (CABG) for multivessel coronary disease.
- Patient enrollment in these trials is limited, but valid conclusions can be drawn.
Purpose of the Study:
- To compare the efficacy and outcomes of PTCA versus CABG in patients with multivessel coronary disease.
Main Methods:
- Analysis of randomized studies including EAST and GABI trials.
- Comparison of perioperative mortality, peri-interventional myocardial infarction, completeness of revascularization, and restenosis rates.
Main Results:
- No significant difference in perioperative mortality between PTCA and CABG.
- Slightly higher risk of peri-interventional myocardial infarction in CABG patients.
- Lower rates of complete revascularization and higher restenosis rates with PTCA compared to CABG.
- PTCA patients had a higher incidence of subsequent revascularization procedures.
Conclusions:
- While perioperative mortality is similar, PTCA is associated with lower revascularization completeness and higher restenosis rates.
- CABG demonstrates superior long-term outcomes regarding the need for repeat interventions.
- Economic factors do not offset the limited efficacy of multivessel PTCA.
Abstract:
Recently several randomized studies have been devoted to a comparative analysis of angioplasty (PTCA) versus bypass surgery (CABG) in patients with multivessel coronary disease. Even though only a very limited number of the screened patients could be randomly assigned to undergo PTCA or CABG (less than 10% of the subjects originally evaluated), some valid conclusions may be drawn. With regard to perioperative mortality, no significant difference between the two treatment groups was evident; considering the incidence of peri-interventional myocardial infarction, a trend towards a slightly higher risk could be detected for the surgical patients (EAST and GABI trials). The most striking differences between the two procedures have been completeness of revascularization and incidence of restenosis. Thus, in the EAST and ERACI trials complete revascularization was achieved only in 75% and 51% respectively of the PTCA patients as compared with 99% and 88% respectively for the CABG patients. Beyond all doubt, the greatest drawback of PTCA is the occurrence of restenosis; in multivessel angioplasty several arterial segments are by definition exposed to development of narrowing at the site of PTCA, resulting in a higher risk of restenosis per patient. In a major angiographic study 50% of patients showed significant restenosis in at least one PTCA segment, and in 14% multiple restenosis were found. The occurrence of restenosis is a substantial reason for the high incidence of further interventions following multivessel angioplasty; thus, in the EAST trial only 46% of the PTCA patients did not require a subsequent revascularization procedure (versus 87% in the surgical group). Economic aspects do not counterbalance the limited efficacy of multivessel angioplasty.(ABSTRACT TRUNCATED AT 250 WORDS)