Revascularization interventions for ischemic heart disease.

Coronary artery bypass grafting and percutaneous transluminal coronary angioplasty are now well established methods of myocardial revascularization. The choice of a method of revascularization depends on several clinical and angiographic parameters. Patients who derive the greatest benefit from coronary artery bypass grafting are those with left main coronary artery disease or those with three-vessel disease with left ventricular impairment. Patients with single-vessel disease achieve more symptomatic relief with coronary angioplasty than with medical therapy alone, but with no improvement in long-term mortality. In nondiabetic patients with multiple-vessel disease, angioplasty and bypass grafting likely yield similar results, and the choice of revascularization technique rests on weighing the more invasive nature of bypass grafting against the need for additional future revascularizations with angioplasty. Diabetic patients with multiple-vessel disease seem to achieve better outcomes with bypass grafting. Minimally invasive bypass surgery is an evolving technique. It is less invasive in nature but its applications are limited, and its advantages over traditional bypass grafting have not yet been shown. Stenting now plays a major role in percutaneous revascularization and is performed in more than two thirds of all interventional procedures. It improves both the short-term and the long-term outcomes of coronary angioplasty. Other novel percutaneous techniques such as directional or rotational atherectomy, laser angioplasty, or thrombectomy devices have not shown convincing superiority over coronary angioplasty alone. Transmyocardial laser revascularization can be performed surgically or percutaneously and may be beneficial in patients with angina refractory to traditional revascularization procedures.