**4. Percutaneous coronary intervention using drug eluted stents**

**3. Advantages of CABG**

354 Artery Bypass

mortality rates. [5,6].

RCA.

Over the last 4 decades, surgical coronary artery revascularization techniques and technology have advanced significantly. As a result, despite an increasingly older and sicker patient population, CABG outcomes continue to improve. For example, the predicted mortality of CABG patients has increased steadily over the past decade, yet observed operative mortality rates have decreased, [4]. This is partly because advances in preoperative evaluation, including more precise coronary artery and myocardial imaging and diagnostic techniques, have allowed more appropriate patient selection and surgical planning. In addition, preoperative, intraoperative, and postoperative monitoring and therapeutic interventions have made CABG safer, even for critically ill and high-risk patients. Improvements in cardiopulmonary perfu‐ sion and careful myocardial protection, as well as the use of off-pump and on-pump beatingheart techniques in selected patients, have also decreased perioperative morbidity and

Use of the bilateral IMAs offers the possibility of constructing various configurations, making to‐ tal arterial myocardial revascularisation possible with a minimum number of arterial conduits. Use of the skeletonised RIMA through the transverse sinus and eventually retrocavally can reach most branches of the circumflex system and is associated with an excellent patency rate. Patients who received bilateral IMA grafts for left coronary system revascularisation had improved ear‐

**Figure 1.** CT coronary angiogram, showing a CABG done 5 years ago with LIMA to LAD artery and SVG to OM and

ly and late outcomes and decreased risk of death, reoperation, and angioplasty. [7].

Percutaneous coronary intervention (PCI) involves dilatation of an obstructed or narrowed coronary artery, using a balloon catheter to dilate the artery from within. After balloon dilatation, a stainless steel stent is usually placed in the coronary artery. Antiplatelet agents like aspirin or clopidogrel are mandatory to be used after stenting. Stents may be either bare metal (BMS) or drug-eluting stents (DES). Indications for PCI might be elective or emergency according to the clinical presentations of the patients. Primary PCI in the setting of ST segment elevation myocardial infarction (STEMI): When the catheterization lab including the team and facility is available, angioplasty with stenting is the optimal method of reperfusion for STEMI. The target "door to balloon time" is 90 minutes, [8]. Rescue PCI is considered as a treatment in patients with thrombolysis - if there is failure to reperfuse, further ischaemia with persistant chest pain, or continuous ST elevation. PCI is considered also as an early invasive strategy in Acute coronary syndrome, Non-ST elevation myocardial infarction (NSTEMI) and unstable angina: [9]., or conservative strategy for patients who are at medium-to-high risk of subsequent cardiac events. Elective PCI for patient with Stable angina or positive stress test: with single or double vessel disease, where optimal medical therapy fails to control symptoms. Patients with triple vessel disease, who are unsuitable for CABG, [10].

**Figure 2.** Cypher Stent- Siroliums eluted stent

A drug-eluting stent presents or releases single or multiple bioactive agents into the blood stream. The drug can deposit in and/or affect blood vessels, cells, plaque, or tissues either adjacent to the stent or at a distance. The drug can be embedded and released from within ("matrix-type") or surrounded by and released through ("reservoir-type") polymer materials that coat ("strut-adherent") or span ("strut-spanning") the struts of the stents. These agents prevent in-stent restenosis by reducing the intimal hyperplasia, [11].

The advantages and a lower cost compared to CABG makes DES an attractive option to treat coronary artery disease. Currently, five DESs are available in the USA: the CYPHER sirolimuseluting stent from Cordis (approved by FDA on 24 April 2003), Figure 2, 3. The TAXUS Express and Liberté paclitaxel-eluting stents from Boston Scientific (approved by FDA on 4 March 2004 and 10 October 2008, respectively) (TAXUS Express is referred to as TAXUS) Figure 4, the ENDEAVOR zotarolimus-eluting stent from Medtronic (approved by FDA on 1 February 2008), and the XIENCE V Figure 5, everolimus-eluting stent from Abbott Vascular (approved by FDA on 2 July 2008). [12].

**Figure 5.** Significan disease of proximal RCA treated by Xience stent

of involvement of the left anterior descending coronary artery LAD.

**implantation**

percent for subsequent PCI), [13].

**5. Outcomes of coronary-artery bypass grafting versus bare metal stent**

Artery Bypass Versus PCI Using New Generation DES

http://dx.doi.org/10.5772/54029

357

The New York's cardiac registries were one of the largest studies which identify 37,212 patients with multivessel disease who underwent CABG and 22,102 patients with multivessel disease who underwent PCI using BMS from January 1, 1997, to December 31, 2000. They determined the rates of death and subsequent revascularization within three years after the procedure in various groups of patients according to the number of diseased vessels and presence or absence

Risk-adjusted survival rates were significantly higher among patients who underwent CABG than among those who received a stent in all of the anatomical subgroups studied. For example, the adjusted hazard ratio for the long-term risk of death after CABG relative to stent implan‐ tation was 0.64 (95 percent confidence interval, 0.56 to 0.74) for patients with three-vessel disease with involvement of the proximal LAD and 0.76 (95 percent confidence interval, 0.60 to 0.96) for patients with two-vessel disease with involvement of the non-proximal LAD. Also, the three-year rates of revascularization were considerably higher in the stenting group than in the CABG group (7.8 percent vs. 0.3 percent for subsequent CABG and 27.3 percent vs. 4.6

Texas Heart Institute Cardiovascular Research Database retrospectively identified patients who had undergone their 1st revascularization procedure with coronary artery bypass surgery (CABG; n=2,826) or coronary stenting (n=2,793) between January 1995 and December 1999. They have found that in-hospital mortality was significantly greater in patients undergoing CABG than in those undergoing stenting (3.6% vs 0.75%; adjusted OR 8.4; *P* <0.0001). At a mean 2.5-year follow-up, risk-adjusted survival was equivalent (CABG 91%, stenting 95%;

**Figure 3.** Complex case with LM disease treated by 2 Cypher stents

**Figure 4.** Taxus stent-Paclitaxal eluted stent

**Figure 5.** Significan disease of proximal RCA treated by Xience stent

A drug-eluting stent presents or releases single or multiple bioactive agents into the blood stream. The drug can deposit in and/or affect blood vessels, cells, plaque, or tissues either adjacent to the stent or at a distance. The drug can be embedded and released from within ("matrix-type") or surrounded by and released through ("reservoir-type") polymer materials that coat ("strut-adherent") or span ("strut-spanning") the struts of the stents. These agents

The advantages and a lower cost compared to CABG makes DES an attractive option to treat coronary artery disease. Currently, five DESs are available in the USA: the CYPHER sirolimuseluting stent from Cordis (approved by FDA on 24 April 2003), Figure 2, 3. The TAXUS Express and Liberté paclitaxel-eluting stents from Boston Scientific (approved by FDA on 4 March 2004 and 10 October 2008, respectively) (TAXUS Express is referred to as TAXUS) Figure 4, the ENDEAVOR zotarolimus-eluting stent from Medtronic (approved by FDA on 1 February 2008), and the XIENCE V Figure 5, everolimus-eluting stent from Abbott Vascular (approved

prevent in-stent restenosis by reducing the intimal hyperplasia, [11].

by FDA on 2 July 2008). [12].

356 Artery Bypass

**Figure 3.** Complex case with LM disease treated by 2 Cypher stents

**Figure 4.** Taxus stent-Paclitaxal eluted stent
