Home > Riviste > The Journal of Cardiovascular Surgery > Fascicoli precedenti > The Journal of Cardiovascular Surgery 2003 June;44(3) > The Journal of Cardiovascular Surgery 2003 June;44(3):307-12

ULTIMO FASCICOLO
 

ARTICLE TOOLS

Estratti

THE JOURNAL OF CARDIOVASCULAR SURGERY

Rivista di Chirurgia Cardiaca, Vascolare e Toracica


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


eTOC

 

I. CURRENT INDICATIONS FOR MYOCARDIAL REVASCULARIZATION  THE MULTIFOCAL ATHEROSCLEROTIC PATIENT
DIAGNOSIS AND MANAGEMENT IN 2003


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

lingua: Inglese

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


PDF  


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.

inizio pagina

Publication History

Per citare questo articolo

Corresponding author e-mail