The Evolution of Coronary Bypass Surgery Will Determine Its Relevance as the Standard of Care for the Treatment for Multivessel Coronary Artery Disease.

Abstract

Despite improvements in percutaneous coronary artery intervention (PCI), coronary artery bypass grafting (CABG) remains the gold standard therapy for the majority of patients with multivessel coronary artery disease. This position has been corroborated by the results of the SYNTAX trial (Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery), which favored CABG over PCI especially in patients with advanced disease involving multiple territories, and a recent meta-analysis performed by Benedetto et al,1 where CABG was compared with PCI with drug-eluting stents (DES-PCI) in 4563 patients. The results showed that, compared with CABG, DES-PCI resulted in a 50% relative increase in the risk for death, a 200% increased risk for myocardial infarction, and a 250% increased risk for repeat revascularization at 3.4 years after revascularization. Most of the survival benefit of CABG may be related to the anastomosis of 1 arterial conduit—usually the left internal thoracic artery—to the left anterior descending (LAD) artery. However, in 1999, the Cleveland Clinic group published results that showed better clinical outcomes in patients in whom 2 internal thoracic arteries were used over a single arterial graft. Today, there is additional published evidence demonstrating that a multiple arterial grafting strategy is associated with a significant survival advantage. In the largest meta-analysis comparing 1 versus 2 arterial grafts for CABG, Yi et al2 reported a 20% survival benefit at 9 years in patients who received two arterial conduits (hazard ratio, 0.79; 95% confidence interval, 0.75–0.84). When the …