Severe coronary artery disease: is there a place for percutaneous coronary intervention?

Management of severe coronary artery disease (CAD), defined as multivessel disease with or without significant left main artery disease remains a topic for considerable discussion. Although coronary artery bypass graft (CABG) surgery has been the mainstay of treatment, the steady pace of improvement in percutaneous coronary intervention (PCI) continues to beg the question as to whether PCI can perform as well as CABG for these patients. This short review is intended to place the recently published SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) trial in perspective, considering the previous major clinical trials in this field and to further consider whether PCI can be used appropriately in the management of patients with advanced CAD. The major clinical trials comparing PCI to CABG published prior to SYNTAX are briefly reviewed in chronologic order. The SYNTAX trial is reviewed in more depth and the implications of its results for contemporary clinical management are discussed. PCI has been applied to more advanced forms of CAD as percutaneous technology has evolved from balloon angioplasty to bare metal stents to drug eluting stents. Long-term survival has remained comparable between PCI and CABG patients despite the more advanced nature of disease treated in more recent trials, recognizing that a significant number of patients are excluded from randomization because equivalent revascularization is not achievable percutaneously. Repeat revascularization is more frequently required in PCI patients than in CABG patients. PCI has a role to play, although CABG remains the mainstay of therapy for patients with advanced CAD.