Indications for percutaneous and surgical revascularisation: how far does the evidence base guide us?

The treatment of patients with coronary artery disease continues to evolve, including those presenting with stable angina pectoris as well as those presenting with acute coronary syndromes. Pharmacological treatments which have changed practice in recent years include statins, angiotensin converting enzyme inhibitors, clopidogrel, and glycoprotein IIb/IIIa inhibitors. There have been major changes in percutaneous coronary intervention (PCI), particularly with the introduction of coronary artery stents. More recently, the appearance of drug eluting stents which may modulate smooth muscle cell proliferation has generated interest, as well as the use of adjunctive pharmacological treatment with stenting. In terms of surgical revascularisation, practice continues to evolve. There has been an expansion in the use of arterial conduits in order to improve long term graft patency. Less invasive approaches for surgery have been developed, as well as the use of “off-pump” coronary artery bypass graft surgery (CABG), in an attempt to reduce the risks associated with surgical revascularisation. Figure 1 shows the increase in the number of both percutaneous and surgical revascularisation procedures undertaken in the UK during the last decade. With this background of continued development of revascularisation techniques together with the introduction of new technologies, it is clear that comparative trials of different approaches for revascularisation in certain clinical situations run the risk of being “out of date” before the study is completed and analysed. In addition, there are often several revascularisation options which could be applied to a particular clinical problem. We will attempt to outline the potential benefits of some of the newer approaches, as well as reviewing some of the comparative trials, which may be of use when managing individual patients who present with problems related to coronary artery disease.