What are the methods for revascularization in patients with Coronary Artery Disease (CAD)?

Methods for Revascularization in Coronary Artery Disease

The two primary methods of coronary revascularization are Coronary Artery Bypass Grafting (CABG) and Percutaneous Coronary Intervention (PCI), with selection between these approaches determined by coronary anatomy complexity, clinical characteristics, and a Heart Team discussion. 1

Heart Team Approach

A multidisciplinary Heart Team approach is recommended when the optimal revascularization strategy is unclear. This team should include:

• Interventional cardiologists
• Cardiac surgeons
• Clinical cardiologists
• Anesthesiologists (when appropriate)

The Heart Team should consider:

• Coronary anatomy complexity (SYNTAX score)
• Patient comorbidities and surgical risk (STS score)
• Patient preferences and goals 1

Revascularization Methods

1. Coronary Artery Bypass Grafting (CABG)

CABG involves creating new routes for blood flow using arterial or venous grafts to bypass blocked coronary arteries.

Key features:

• Conduits:

  • Left Internal Mammary Artery (LIMA) to LAD is the gold standard 1
  • Radial artery is preferred over saphenous vein for the second most important target vessel 1
  • Saphenous vein grafts for additional targets

• Techniques:

  • On-pump (traditional with cardiopulmonary bypass)
  • Off-pump (beating heart surgery)
  • Minimally invasive approaches

2. Percutaneous Coronary Intervention (PCI)

PCI involves catheter-based techniques to restore blood flow through blocked coronary arteries.

Key features:

• Stent types:

  • Drug-eluting stents (DES) - preferred in most scenarios
  • Bare-metal stents (BMS) - limited use
  • Bioresorbable vascular scaffolds - emerging technology

• Access routes:

  • Radial artery access (preferred) - reduces bleeding, vascular complications, and mortality in ACS 1
  • Femoral artery access

Indications for Specific Revascularization Methods

Left Main Coronary Artery Disease

• CABG is recommended for significant left main disease (≥50% stenosis) to improve survival compared to medical therapy 1
• PCI is a reasonable alternative in selected patients with:
  • Low to medium anatomic complexity (SYNTAX score ≤22)
  • High surgical risk (STS-predicted operative mortality ≥5%) 1

Multivessel Coronary Artery Disease

• CABG is preferred for:
  • Three-vessel disease with intermediate to high CAD burden (high SYNTAX score)
  • Presence of chronic total occlusions (CTOs) 1
• PCI may be considered for:
  • Two-vessel disease without proximal LAD involvement
  • Three-vessel disease with low CAD burden (low SYNTAX score) 1, 2

Diabetes with Multivessel CAD

• CABG is strongly recommended over PCI to reduce mortality and repeat revascularizations 1
• PCI may be considered only if patients are poor candidates for surgery 1

Acute Coronary Syndromes

• Primary PCI is preferred for STEMI when available within guideline-recommended timeframes
• For multivessel disease in STEMI:
  • Staged PCI of non-culprit arteries is recommended in select patients
  • Immediate multivessel PCI may be considered in stable patients with uncomplicated revascularization of the culprit artery 1

Risk Stratification Tools

• Society of Thoracic Surgeons (STS) score - recommended to stratify surgical risk for CABG 1
• SYNTAX score - assesses coronary anatomy complexity; useful but has limitations including interobserver variability 1

Common Pitfalls and Caveats

1. Incomplete revascularization - Associated with worse outcomes; aim for complete functional revascularization when possible

2. Inappropriate selection of revascularization method - Consider both anatomical complexity and patient factors; avoid PCI in complex multivessel disease with high SYNTAX scores when CABG is feasible

3. Ignoring diabetes status - Patients with diabetes and multivessel disease generally have better outcomes with CABG than PCI 2

4. Neglecting guideline-directed medical therapy (GDMT) - All patients should receive optimal medical therapy regardless of revascularization strategy 1

5. Overlooking radial access benefits - Radial approach reduces bleeding and vascular complications compared to femoral approach 1

By following these evidence-based recommendations and utilizing a Heart Team approach, clinicians can optimize revascularization decisions to improve survival, reduce symptoms, and enhance quality of life for patients with coronary artery disease.