**3. Advantages of CABG**

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 mortality rates. [5,6].

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

with triple vessel disease, who are unsuitable for CABG, [10].

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

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

Artery Bypass Versus PCI Using New Generation DES

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

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