Hybrid Procedures Have Proven Clinical Utility and Are the Wave of the Future

Abstract

The optimal revascularization strategy for multivessel coronary artery disease remains controversial, especially when there is diffuse disease involving the proximal segment of the left anterior descending artery (LAD). Coronary artery bypass graft surgery (CABG) remains the gold standard approach, although the evidence is increasingly being challenged by technological and procedural advances in percutaneous coronary intervention (PCI). The well-established survival benefit of surgery1–3 is conferred by the left internal mammary arterial (LIMA) graft to the LAD, which, through its resistance to thrombosis and atherosclerosis,4 has demonstrated patency rates of 95% to 98% at 10 years.5,6 Moreover, the LIMA has been shown to protect the proximal LAD territory against further ischemic injury from progressive disease.4 However, the incremental benefit of concomitant saphenous vein grafts (SVGs) supplying non-LAD territories is less clear.2,3 The longevity of vein grafts is relatively poor, with reported failure rates averaging 20% at 1 year and reaching up to 70% at 15 years.6–8 Interestingly, the Project of Ex-vivo Vein graft Engineering via Transfection IV (PREVENT IV) trial investigators reported an SVG failure rate of 45% at 12- to 18-month angiographic follow-up,7 a figure that, in the modern era, seems unacceptable. Response by Leacche et al on p 2503 So, is CABG a double-edged sword? It certainly seems plausible that the prognostic benefit conferred by the longevity of the LIMA-to-LAD graft might, in some way, be offset by the disappointing survival rates of SVG to non-LAD vessels. Although vein graft occlusion is certainly as frequent as stent thrombosis,9 stent thrombosis is characteristically associated with a higher incidence of major adverse cardiac events. Vein graft narrowing, in contrast, is at least 2 or 3 times more frequent than stent restenosis, although both tend to be …