The choice between coronary artery stent placement and coronary artery bypass grafting (CABG) depends on various factors, including the complexity of the coronary artery disease, patient-specific characteristics, and the risk of restenosis. Both procedures have their own advantages and limitations.
Clinical outcomes
- Survival and major adverse cardiac events: CABG is generally associated with better survival outcomes and lower rates of major adverse cardiac and cerebrovascular events in patients with complex or diffuse coronary artery disease, particularly those with significant left main stenosis or multivessel disease
- Repeat revascularization: Stent placement, particularly with drug-eluting stents, is associated with a higher incidence of repeat revascularization compared to CABG
- Restenosis: The risk of restenosis is a significant limitation of percutaneous coronary interventions (PCI). The relative health status benefits of CABG compared with PCI increase as the risk of restenosis increases
- Neuropsychological outcomes: There is no significant difference in neuropsychological outcomes between patients treated with PCI and those treated with CABG
Technical considerations
- Choice of stent: Drug-eluting stents are preferred over bare-metal stents to prevent restenosis, myocardial infarction, or acute stent thrombosis in patients undergoing PCI
- Choice of graft: The use of an internal mammary artery, preferably the left, to bypass the left anterior descending artery is recommended to improve survival and reduce recurrent ischemic events in patients undergoing CABG
Patient-specific factors
- Complexity of disease: CABG is preferred over PCI in patients with high-complexity coronary artery disease, as indicated by a SYNTAX score greater than 33
- Left main coronary artery disease: CABG is considered the gold standard treatment for unprotected left main coronary artery disease
In conclusion, the choice between coronary artery stent placement and CABG should be individualized, taking into account the complexity of the disease, patient-specific factors, and the risk of restenosis. CABG generally provides better outcomes in terms of survival and major adverse cardiac events, particularly in patients with complex or diffuse coronary artery disease. However, stent placement may be a suitable option for selected patients with less complex lesions or those who are poor surgical candidates.