Best practices in coronary revascularization procedures: are we where we should be?
PURPOSE OF REVIEW: To address the most recent evidence bases for coronary artery bypass grafting (CABG) and stenting in patients with multivessel and left main coronary artery disease (CAD) and for optimizing the performance of CABG with particular reference to multiple arterial grafts, off-pump and less invasive CABG, graft flow measurements and external stenting of vein grafts. RECENT FINDINGS: Current evidence confirms that CABG results in markedly superior survival to stenting for most patients with multivessel and/or left main stem CAD, as well as a significant reduction in subsequent myocardial infarction and repeat revascularization. Whereas there is strong circumstantial evidence of important survival benefits with bilateral internal mammary arteries, there is no evidence for clinical benefits of off-pump CABG, except perhaps in higher-risk patients. There appears to be increasing justification for routine graft flow measurements, while minimally invasive and robotic CABG remains as a niche specialty. SUMMARY: CABG remains the most effective revascularization strategy in terms of survival and freedom from myocardial infarction and repeat revascularization in most patients with multivessel and/or left main stem CAD. There is a strong case for much wider use of bilateral internal mammary arteries during CABG, and off-pump CABG may be beneficial in higher-risk patients with particular reference to reducing neurologic injury. There is a strong rationale for the routine use of graft flow measurement, and particularly when using composite arterial grafts. There is a potential role for the development of an external stent to reduce the development of intimal hyperplasia in vein grafts.