[PTCA or bypass surgery in multi-vessel coronary disease? Viewpoint of the surgeon]

Abstract

Recently several randomized studies have been devoted to a comparative analysis of angioplasty (PTCA) versus bypass surgery (CABG) in patients with multivessel coronary disease. Even though only a very limited number of the screened patients could be randomly assigned to undergo PTCA or CABG (less than 10% of the subjects originally evaluated), some valid conclusions may be drawn. With regard to perioperative mortality, no significant difference between the two treatment groups was evident; considering the incidence of peri-interventional myocardial infarction, a trend towards a slightly higher risk could be detected for the surgical patients (EAST and GABI trials). The most striking differences between the two procedures have been completeness of revascularization and incidence of restenosis. Thus, in the EAST and ERACI trials complete revascularization was achieved only in 75% and 51% respectively of the PTCA patients as compared with 99% and 88% respectively for the CABG patients. Beyond all doubt, the greatest drawback of PTCA is the occurrence of restenosis; in multivessel angioplasty several arterial segments are by definition exposed to development of narrowing at the site of PTCA, resulting in a higher risk of restenosis per patient. In a major angiographic study 50% of patients showed significant restenosis in at least one PTCA segment, and in 14% multiple restenosis were found. The occurrence of restenosis is a substantial reason for the high incidence of further interventions following multivessel angioplasty; thus, in the EAST trial only 46% of the PTCA patients did not require a subsequent revascularization procedure (versus 87% in the surgical group). Economic aspects do not counterbalance the limited efficacy of multivessel angioplasty.(ABSTRACT TRUNCATED AT 250 WORDS)