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Abstract
The major value of percutaneous or surgical coronary revascularization is the relief of symptoms and signs of ischemic CAD. However, the choice of CABG versus PCI (BMS or DES) is a complicated decision. Bypass surgery usually requires thoracotomy with extracorporeal circulation and carries its substantial risk of morbidity and death. In contrast, multivessel coronary stenting is relatively free of these complications, but the need for repeat revascularization remains the major limitation of this therapy.
In fact, PCI and CABG should be considered complementary rather than competitive revascularization strategies.
PCI should be considered when one, two or even three coronary arteries have become narrowed, provided that the arteries are suitable for angioplasty. When there is significant narrowing of the left main coronary artery or of all three major coronary arteries, CABG should be considered.
On the other hand, in selected patients with multivessel coronary artery disease and normal left ventricular function, intracoronary stenting may offer an effective alternative to coronary bypass surgery
Data from the majority of the randomized clinical trials showed that CABG provides more effective angina relief and less need for repeat revascularization, but offered no survival benefit over PCI, except in patients with diabetes. Three-year survival of diabetic patients who underwent CABG was better than that of diabetics who underwent myocardial revascularization with stents.
There was a sustained and significant reduction in the need for reintervention after the placement of SES compared with BMS. Therefore, the use of DES reduced the rate of repeat revascularization. But the risk of late stent thrombosis with DES was greater than that seen with BMS.
How will DES alter the outcomes of coronary intervention! Just as bare metal stenting decreased restenosis and subsequent reintervention after PCI as compared with balloon angioplasty, DES have decreased restenosis and subsequent revascularization after PCI compared with BMS. However, the lower rate of restenosis found with DES didn’t improve the survival of patients undergoing PCI.
Mortality and MI rates were low and similar for DES and BMS. The rate of MACE of death, MI or target vessel revascularization was lower with DES than with BMS.
In conclusion, the results of all the discussed trials show that CABG, as compared with PCI, is associated with a lower rate of MACCE at 1 year among patients with three-vessel or left main coronary artery disease (or both) and should therefore remain the standard of care for such patients.
The Off-label use of DES should be controlled as mentioned because it increases the rate of mortality and MACE. And only a special population of patients - who are compliant with intake of dual antiplatelet therapy and those who are fulfilling the new current guidelines criteria for DES implantation - shall be treated with those stents.