Importance of considering atherosclerosis progression when choosing a coronary revascularization strategy: the diabetes-percutaneous transluminal coronary angioplasty dilemma.

The choice of which coronary revascularization strategy is best for diabetic patients with multivessel coronary disease has always been complex. The presence of diabetes, especially insulin-requiring diabetes, has been associated with higher rates of acute and late-term adverse events for both PTCA1 and bypass surgery,2 making either approach seemingly suboptimal. The results of the Bypass Angioplasty Revascularization Investigation (BARI) trial,3 however, strongly suggest that bypass surgery is the treatment of choice over PTCA. High restenosis rates,4 inability to fully revascularize all ischemic territories,5 and progression of atherosclerosis6–8 are generally cited as the major problems that limit the effectiveness of percutaneous coronary revascularization (PCR) in diabetic patients. But in everyday practice when patients are found to have clinical ischemia and multivessel disease at coronary angiography, the choice of revascularization approach is often based largely on the feasibility of PCR, with little regard for the presence or absence of diabetes. Is this decision-making process wrong? Lack of finding a detrimental PTCA treatment effect for diabetics in other randomized trials or large clinical databases,2,9,10 limited clinical follow-up (#6 years) that cannot measure the impact of probable late-term bypass vein graft failure in patients who receive initial bypass surgery, and lack of outcomes reflecting coronary stenting are generally cited as the major factors that limit the notion that surgery is the treatment of choice. Moreover, initial experiences with radiation therapy11 and the glycoprotein IIb/IIIa receptor blocker abciximab12 have shown promising reduction in late loss within stents of diabetic patients and further support the hope for a PCR solution in some subsets of diabetic patients with multivessel disease. Presently, pending the 10-year follow-up results of the BARI trial and the results of 2 ongoing coronary-stent versus bypass-surgery trials (Arterial Revascularization Therapy Study [ARTS] and the Stent Or Surgery trial [SOS]), surgical bypass has become the accepted treatment for nonselected diabetic patients with multivessel disease.7 Exactly why bypass surgery appears to be superior to PCR and whether selected diabetic patients with multivessel disease may benefit from PCR both now and in the future may be better understood if one focuses on the impact of atherosclerosis progression after successful coronary revascularization and examines the comparison of the BARI randomized trial and its parallel registry.13