Status of percutaneous coronary intervention and coronary artery bypass.

At present a rapid and profound change in myocardial revascularization has evolved from the work of Gruentzig. The recent technological advances have been so fast paced that there has not been ample time to fully assess each new facet of technology and pharmaceutics before another arrives. The interface between percutaneous intervention (PCI) and coronary artery bypass (CAB) is not well defined as previously so that continental, national and regional differences exist. The progress in PCI from balloon angioplasty to drug eluting stents has seen a progressive decline in restenosis and reintervention but relief of symptoms has not equaled that attained with CAB. Survival benefit for CAB over PCI has not been demonstrated in the many randomized clinical trials which are limited by selection of only 5-12% of potential patients so that higher risk patients and those with more extensive and complex coronary disease are excluded. These excluded patients are included in the registries where survival benefit for CAB over PCI is clearly evident. Situations less amenable to PCI include: left main disease; three vessel disease; vessels that are smaller, diffusely diseased or with distal lesions which are frequently associated with diabetes; ostial and bifurcation lesions; and coronary arteries that are tortuous, calcified or with very long lesions. It is in these situations that PCI does not provide revascularization equivalent to CAB. Surgeons must appreciate the success of PCI, acknowledge their reduced role in revascularization and strive to provide the best operation possible when the clinical situation demands it.