Multivessel Coronary Artery Disease3V CAD

PCI vs CABG

Michael Zairis, MD, PhD, FESC

Interventional Cardiologist

Director at Metropolitan Hospital

What is our goal of therapy?

• Prevent complications of CAD in effort to

prolong life

• Decrease cardiac morbidity

• Alleviate symptoms

What are the indications for revascularization?

• Activity limiting symptoms despite maximal medical therapy

• Not tolerating medication well or need to increase activity level

• Anatomy favors survival benefit (significant LMCA disease or multivesselCAD with decreased LVEF)

Will the debate go on forever?

• Balloon angioplasty vs CABG

– BARI

– RITA

– GABI

– EAST

– CABRI

Will the debate go on forever?

• Bare metal stent vs CABG

– ERACI - II

– ARTS

– SOS

• Drug eluting stents vs CABG

– ARTS - II

– ERACI – III

– SYNTAX

SYNTAX Trial

• CABG vs PCI in 3 vessel or LMCA disease

– 60% patients were 3V CAD

– 40% LMCA disease

– Paclitaxel was the DES used

Patient 1

Patient 1 Patient 2

Patient 2

SYNTAX SCORE 21 SYNTAX SCORE 52

LCx 70-90%

LAD 70-90%

RCA2 70-90%

RCA3 70-90%

LM 99%

LCx 100%

LAD 99%

RCA 100%

There is ‘3-vessel disease’ and ‘3-vessel disease’

• How the score was calculated– Amount of segments involved– If a CTO was present and if so

what type– Bifurcation vs trifurcation lesions– Ostial lesions– Tortuosity– Long segment disease– Small vessel disease

SYNTAX Trial

• Composite primary endpoint was higher in PCI vs CABG (17.8% vs 12.4%)

– Death/MI/Repeat revascularization

– This was driven by revascularization (13.5% vs 5.9%)

– Death/Stroke/MI were comparable

– At 3 and 5 year follow up, primary endpoint remained higher in PCI group (driven by revascularization)

SYNTAX Trial

• Outcomes were then broken down by disease complexity• SS < 23 - no difference in composite

endpoint

• SS 23-32 - endpoint was higher with PCI (37.9% vs 22.6%)

• SS > 33 - endpoint was higher with PCI (41.9% vs 24.1%)

SYNTAX Trial

• Criticisms

• No clinical variables

• Use of paclitaxel (increased rate of angiographic and clinical restenosis than later generations)

• Bypass patients were often not on “maximal” medical therapy

SYNTAX Trial

SYNTAX II• Additional scoring factors

• Anatomical syntax score• Age• Creatinine clearance• LVEF• Presence of unprotected LMCA disease• PAD• Female sex• COPD

SYNTAX II• Additional PCI Developments

• (SYNERGY™ and/or SYNERGY II™ DES)

• (iFR/FFR) to allow for ischemia-driven revascularisation and

• IVUS guidance to optimise stent deployment.

• If present, chronic total occlusion (CTO) lesions will be treated with contemporary techniques.

• 2 vessel CAD especially if LAD is not involved

• Older patients with significant comorbidities

• Patients who refuse surgery

• Patients with low complexity disease that do not have diabetes

PCI preferred

PCI or CABG

• If patients are equally suited• Decision should be made by joint team

• Patients willingness to undergo repeat procedures should be assessed

• Patients should be aware of slightly higher stroke risk with CABG vs PCI

• Should not be attempted by low volume operators

• Assess ability to take DAPT for a long period of time

The Future?