Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Patients With Left Main and Multivessel Coronary Artery Disease
Do We Have the Evidence?
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Approximately 60 randomized controlled trials performed over the last 3 decades have failed to demonstrate statistically significant differences in death or myocardial infarction (MI) between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI), apart from a few notable exceptions in which CABG was superior to PCI. The benefits for CABG have been reported in patients with diabetes mellitus with multivessel disease and in patients with and without diabetes mellitus with 3-vessel disease and intermediate or high SYNTAX trial (Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery) scores (≥23). 1
In theory, although PCI is limited to treatment of culprit lesions, by bypassing the length of the epicardial vessel, CABG may address both today’s and tomorrow’s culprits by bypassing vulnerable plaques responsible for future adverse events.2 This mechanism may underlie the effectiveness of CABG in patients with extensive coronary disease.
However, most completed trials in multivessel disease may have limited relevance to contemporary practice because of technological and pharmacological advances that have changed the practice of PCI, including the introduction of safer and more effective drug-eluting stents; more judicious use of PCI, based on fractional flow reserve measurements; PCI optimization with intravascular ultrasound and optimal coherence tomography; and improved antithrombotic and antiplatelet agents. In addition, the use of risk stratification and assessment tools, such as the baseline and residual SYNTAX scores, which assess the potential extent of revascularization, may be helpful in identifying patients who may have …