Innovation, evidence and the real world. A surgeon's perspective on the treatment of three-vessel or left main coronary artery disease with drug-eluting stents.

Percutaneous coronary intervention has been at the forefront of innovation, driven by the need to find less invasive but still safe and effective ways to treat patients with coronary artery disease. There has been real progress but high expectations at each innovative step have been repeatedly followed by a more realistic appraisal. Although the evidence-generation process for the treatment of stable angina can be debated, guidelines are the basis of clinical practice and these consider coronary artery bypass surgery the preferred treatment for left main or three-vessel coronary artery disease, particularly in diabetic patients. The current practice of multivessel drug-eluting stenting for three-vessel disease, particularly in those with diffuse disease, diabetes or unprotected left main disease, is based more on hype and hope than scientific evidence. Moreover, safety concerns regarding drug-eluting stents and the need for dual antiplatelet therapy for an unknown period to prevent late stent thrombosis make this practice questionable, particularly in the setting of untested conditions. The best treatment for the patient with stable angina and three-vessel coronary artery disease or left main disease should be discussed within multidisciplinary teams.