Optimal Treatment for Myocardial Revascularization: Surgery or Stenting?

Since the introduction of coronary artery bypass grafting (CABG) in 1967, and percutaneous transluminal coronary angioplasty (PTCA) 10 years later, several major clinical trials have been conducted comparing the two therapeutic strategies, such as the Bypass Angioplasty Revascularization Investigation (BARI) (1) and the Coronary Angioplasty versus Bypass Revascularization Investigation (CABRI) (2) trials. The seven-year outcome data of the BARI trial (involving 1,829 patients) demonstrated that CABG carried a significant survival benefit over PTCA and this was particularly pronounced in diabetic patients (1). In addition, nearly 60% of the patients treated with PTCA had to undergo repeat revascularization procedures and half of them relied on CABG as a subsequent therapy (1). Nevertheless, the past two decades have witnessed a rapid progression of PTCA technology, in particular the development of intra-coronary stents. Drug-eluting stents (DES) especially, appear to have impacted significantly on the current daily practice of treating patients with coronary artery disease (3). These advances and their immediate influence on clinical practice provide a good example of how technology may shift the paradigm of medicine. Consequently, the mechanism and technique of revascularization needs to be redefined in the present era.