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Percutaneous coronary intervention versus coronary artery bypass graft surgery 

Percutaneous coronary intervention versus coronary artery bypass graft surgery
Chapter:
Percutaneous coronary intervention versus coronary artery bypass graft surgery
Author(s):

Dr Richard Varcoe

and Dr Robert Henderson

DOI:
10.1093/med/9780199594764.003.0007
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date: 19 September 2019

Obstructive coronary artery disease causing symptomatic myocardial ischaemia can be treated with anti-anginal medication or by myocardial revascularization, with either coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI). Coronary artery bypass graft surgery began in the 1960s and rapidly became a routine treatment for patients with symptomatic coronary artery disease. Long-term clinical outcomes have improved with advances in surgical technique, particularly the use of internal mammary artery grafts.

Percutaneous coronary intervention was first performed in 1977 and was initially considered appropriate only in patients with an isolated proximal coronary artery stenosis. Technological advances, particularly the introduction of bare metal then drug eluting stents, together with developments in adjunctive pharmacology have improved clinical outcomes and expanded the indications for PCI to the treatment of more complex lesions and patient subsets, including those with multi-vessel and left main stem disease.

For some patients with multi-vessel coronary artery disease (CAD) both methods of myocardial revascularization may be technically feasible, but the optimal treatment strategy is uncertain. A number of randomized controlled trials have compared initial treatment strategies of CABG and PCI in patients who were considered to be clinically and angiographically suitable for either procedure and in whom there is equipoise about the most appropriate method of myocardial revascularization. These trials fall into several distinct eras as PCI technology has developed from balloon angioplasty, to bare metal, and then drug eluting stents. This chapter reviews the landmark trials from each of these three eras.

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