Left Main Coronary Artery Disease in Diabetics: Percutaneous Coronary Intervention or Coronary Artery Bypass Grafting?

Abstract

The choice between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for myocardial revascularization in patients with left main disease (LMD) is controversial. There is general agreement that CABG is appropriate for all patients, and PCI is acceptable for those with low-to-intermediate anatomic complexity. However, there is uncertainty about the relative safety and efficacy of PCI in patients with more complex LMD and with comorbidities such as diabetes. No direct comparison trial has focused on revascularization in diabetic patients with LMD, and thus conclusions on the topic are subject to the limitations of subgroup analysis, as well as the heterogeneous exclusion criteria, and methodologies of individual trials. The available evidence suggests that among diabetics, CABG is superior in patients with LMD with SYNTAX (SYNergy between percutaneous coronary intervention with TAXus and dardiac surgery) score greater than 33, distal bifurcation disease, or multivessel disease. PCI may be appropriate in those with less-extensive disease or those with limited life expectancy or high surgical risk.

Keywords: PCI; cardiac surgery; cardiovascular risk factors; coronary artery; coronary intervention; insulin resistance; left main coronary artery disease.

Fig. 1

Timeline of major developmental milestones in PCI and CABG. BMS, bare metal stenting; CABG, coronary artery bypass grafting; DES, drug-eluting stent; ITA, internal thoracic artery; LAD, left anterior descending artery; PCI, percutaneous coronary intervention; LITA, left internal thoracic artery; SVG, saphenous vein graft.