Brown Matthew A, Klusewitz Seth, Elefteriades John, Prescher Lindsey
Department of Cardiac Surgery, Georgetown University School of Medicine, Washington, District of Columbia.
Department of Cardiology, Walter Reed National Military Medical Center, Bethesda, Maryland.
Int J Angiol. 2021 Nov 10;30(3):228-242. doi: 10.1055/s-0041-1735591. eCollection 2021 Sep.
The question of percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) surgery remains among the most important questions in the treatment of coronary artery disease. The leading North American and European societies largely agree on the current guidelines for the revascularization of unprotected left-main disease (ULMD) and multivessel disease (MVD) which are largely supported by the outcomes of several large randomized trials including SYNTAX, PRECOMBAT, NOBLE, and EXCEL. While these trials are of the highest quality, currently available, they suffer several limitations, including the use of bare metal and/or first-generation drug-eluting stents in early trials and lack of updated surgical outcomes data. The objective of this review is to briefly discuss these key early trials, as well as explore contemporary studies, to provide insight on the current state of coronary revascularization. Evidence suggests that in ULMD and MVD, there are similar mortality rates for CABG and PCI but PCI is associated with fewer "early" strokes, whereas CABG is associated with fewer "late" strokes, myocardial infarctions, and lower need for repeat revascularization. Additionally, studies suggest that CABG remains superior to PCI in patients with intermediate/high SYNTAX scores and in MVD with concomitant proximal left anterior descending (pLAD) artery stenosis. Despite the preceding research and its basis for our current guidelines, there remains significant variation in care that has yet to be quantified. Emerging studies evaluating second-generation drug-eluting stents, specific lesion anatomy, and minimally invasive and hybrid approaches to CABG may lend itself to more individualized patient care.
经皮冠状动脉介入治疗(PCI)与冠状动脉旁路移植术(CABG)孰优孰劣,仍是冠状动脉疾病治疗领域最重要的问题之一。北美和欧洲的主要学会在很大程度上就目前无保护左主干病变(ULMD)和多支血管病变(MVD)血运重建的指南达成了一致,这些指南在很大程度上得到了包括SYNTAX、PRECOMBAT、NOBLE和EXCEL等多项大型随机试验结果的支持。虽然这些试验是目前可获得的质量最高的试验,但它们存在一些局限性,包括早期试验中使用裸金属支架和/或第一代药物洗脱支架,以及缺乏更新的手术结果数据。本综述的目的是简要讨论这些关键的早期试验,并探讨当代研究,以深入了解冠状动脉血运重建的现状。有证据表明,在ULMD和MVD中,CABG和PCI的死亡率相似,但PCI与较少的“早期”中风相关,而CABG与较少的“晚期”中风、心肌梗死以及较低的再次血运重建需求相关。此外,研究表明,在SYNTAX评分中/高的患者以及伴有左前降支近端(pLAD)动脉狭窄的MVD患者中,CABG仍优于PCI。尽管有上述研究及其作为我们当前指南的基础,但治疗方面仍存在显著差异,尚未进行量化。评估第二代药物洗脱支架、特定病变解剖结构以及CABG的微创和杂交方法的新兴研究,可能有助于实现更个体化的患者护理。