Treatment of multi-vessel coronary artery disease. What is the optimal revascularisation approach? What do we know, what will we learn?

C oronary artery bypass grafting (CABG) has long been the definitive, but nevertheless aggressive therapeutic approach for the treatment of patients with multi-vessel coronary artery disease. On the other hand, continuous improvement of devices and percutaneous techniques in interventional cardiology has led from the limited treatment of single, simple lesions to the extensive management of multiple and severely complex stenoses. Historical data from the early trials comparing percutaneous coronary intervention (PCI) with bare metal stent implantation and surgical revascularisation showed that there were no differences in terms of mortality and myocardial infarction. However, a more favourable outcome was observed in the CABG arm regarding repeat revascularisation and long-term relief from angina. The largest multi-centre, randomised studies were conducted in the mid to late 1990s. The Angina With Extremely Serious Operative Mortality Evaluation (AWESOME) trial was one of the first randomised, multi-centre studies to show that there is no significant difference in the global survival or the combined endpoint of survival free of unstable angina among patients with multi-vessel disease treated with CABG or PCI with stent implantation. These results were sustained up to three years’ follow up. However, survival free of unstable angina and repeat revascularisations was observed to be generally greater in the surgical group than in the PCI group. The ERACI II study (Argentine Randomised Study: Coronary angioplasty with stenting vs. coronary bypass surgery in multi-vessel disease) included 450 patients. ERACI II showed better survival and freedom from myocardial infarction in the PCI arm compared with the surgical cohort. This difference in favour of the PCI strategy was mainly observed during the first 30 days, when more patients died in the surgical group, and disappeared after one month. The surgical hospital mortality in the ERACI II study was higher than in other trials, but was mainly observed in patients with severe unstable angina. On the other hand, freedom from the need for new revascularisation procedures and major adverse cardiovascular events were significantly better with CABG patients. 6 The SoS (Stent or Surgery) trial was conducted in 53 centres in Europe and Canada and randomised 988 patients. Of the patients initially randomised to PCI, 21% required one or more additional revascularisation procedures, whereas in the surgical cohort only 6% underwent additional PCI or CABG (p<0.0001). The incidence of death or non-fatal Q-wave myocardial infarction was similar in both groups, Treatment of Multi-Vessel Coronary Artery Disease. What Is the Optimal Revascularisation Approach? What Do We Know, What Will We Learn?