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CURRENT ISSUETHE JOURNAL OF CARDIOVASCULAR SURGERY

A Journal on Cardiac, Vascular and Thoracic Surgery

Indexed/Abstracted in: BIOSIS Previews, Current Contents/Clinical Medicine, EMBASE, PubMed/MEDLINE, Science Citation Index Expanded (SciSearch), Scopus
Impact Factor 1,632

Frequency: Bi-Monthly

ISSN 0021-9509

Online ISSN 1827-191X

 

The Journal of Cardiovascular Surgery 2003 June;44(3):307-12

THE MULTIFOCAL ATHEROSCLEROTIC PATIENT
DIAGNOSIS AND MANAGEMENT IN 2003 

    I. CURRENT INDICATIONS FOR MYOCARDIAL REVASCULARIZATION

Indications of coronary angioplasty and stenting in 2003: what is left to surgery?

Poyen V., Silvestri M., Labrunie P., Valeix B.

Cardiovascular Unit U.C.V. Marseille, France

For ­many ­years, cor­o­nary ­artery by-pass ­graft (­CABG) ­remained ­the ­only effec­tive treat­ment of mul­ti­ves­sel dis­ease com­pared to med­i­cal treat­ment. The ­first tech­ni­cal rev­o­lu­tion ­was in 1977 ­when Gruentzig intro­duced bal­loon per­cut­ane­ous trans­lu­mi­nal cor­o­nary angio­plas­ty (­PTCA), ­the 2nd in ­the 90’s ­with ­the devel­op­ments of ­stents ­and anti­ag­gre­gant pro­to­cols. The equip­ment ­for ­PTCA ­became ­more ­and ­more sophis­ti­cat­ed, ­and ­the ­skill of car­di­ol­o­gists great­er. In ­the 90’s, inter­ven­tion­al car­di­ol­o­gy ­played a pre­dom­i­nant ­role in revas­cu­lar­iza­tion as ­the num­ber of ­CABG ­decreased at ­the ­same ­time, ­and emer­gen­cy ­CABG ­for ­bail ­out ­almost dis­ap­peared (0% to 0.5%). Systematic stent­ing ­decreased ­the ­need ­for ­repeat revas­cu­lar­iza­tion to ­about 18-20% now­a­days in ­the major­ity of cen­ters, ­except in dia­bet­ic ­patients. Despite ­this ­fact resten­o­sis ­remains ­the pit­fall of angio­plas­ty, most­ly in dia­bet­ic ­patients pre­sent­ing mul­ti­ves­sel dis­ease in ­which sur­gery ­with “­all arte­ri­al ­grafts” ­gives ­good ­long ­term ­results. The ­first stud­ies com­par­ing ­PTCA ­and ­CABG ­are favour­able to sur­gery (­BARI), ­then ­late ­ones ­using ­stents (­ARTS, ERA­CI 2) ­showed ­that stent­ing ­was at ­least equiv­a­lent to ­CABG, in ­terms of mor­tal­ity or seri­ous com­pli­ca­tions (­major ­acute cor­o­nary ­events, ­MACE), ­despite a high­er tar­get ves­sel revas­cu­lar­isa­tion (­TVR) main­ly ­due to resten­o­sis in ­the angio­plas­ty ­cohort. The ­same ­results ­are ­observed by stent­ing a ­high ­risk ­lesion as ­the unpro­tect­ed ­left ­main sten­o­sis ­can be, ­until ­then treat­ed sur­gi­cal­ly. However, ­high vol­ume cen­ters stud­ies treat­ing by ­PTCA+­stent ­the unpro­tect­ed ­left ­main ­artery (­LMA) ­shows ­that ­the 1 ­year sur­vi­val ­rate is sim­i­lar to sur­gery, ­but ­always relat­ed to a resten­o­sis ­rate of 20% at 6 ­months in ­the ­stent ­group, ­which rep­re­sents ­the ­only sig­nif­i­cant dif­fer­ence in ­terms of ­MACE; ­the ­new ­drug elut­ing ­stents ­lead us to ­expect, accord­ing to SIR­I­US ­and TAX­US II stud­ies, to ­reduce ­the resten­o­sis ­rate, ­and by ­the ­way, ­the ­MACE ­could be dra­mat­i­cal­ly low­ered ­from 50% to 60%. Randomised stud­ies ­would be nec­es­sary, ­but ­the extrap­o­la­tion of ­the actu­al ­data, ­more par­tic­u­lar­ly ­results of ­subgroups ­with a ­high ­risk of resten­o­sis, dia­bet­ic ­patients ­and ­small ves­sels, ­lead us to ­think ­that stent­ing ­could ­come in ­first inten­tion ­before sur­gery if ­TVR is sig­nif­i­cant­ly ­reduced. A com­plex anat­o­my, ­failed attempt­ed chron­ic occlu­sion, sev­er­al ­lesions on tor­tu­ous ves­sels, ­would ­remain ­the ­last sur­gi­cal indi­ca­tion if ­CABG pro­vides a ­more com­plete revas­cu­lar­iza­tion. The ­impact of ­these ­new ­drugs ­seems prom­is­ing. However, we ­should ­await ear­ly ­results of stud­ies in dia­bet­ic ­patients ­and bifur­ca­tions. But in ­high vol­ume expe­ri­enced cen­ters, ­CABG indi­ca­tions ­would be ­reduced in ­the ­future to ­the tech­ni­cal pit­falls of stent­ing (com­plex or tor­tu­ous anat­o­my, chron­ic occlu­sions…) or to ­the ­adverse addi­tion­al ­cost of ­this ­device, ­unless reduc­tion of resten­o­sis or ­TVR ­could ­also can­cel ­this ­extra ­cost. We ­expect ran­dom­ised stud­ies ­CABG ver­sus stent­ed angio­plas­ty ­using ­drug elut­ing ­stents to con­firm ­these pre­lim­i­nary ­data.

language: English


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