Revascularization refers to a set of surgical procedures aimed at managing coronary artery disease (CAD). One of the leading causes of morbidity and mortality in the world, CAD can have severely detrimental effects on a patient’s life.
The primary goal of revascularization is to restore blood flow to the heart. This can alleviate common CAD symptoms such as angina and reduce the risk of patients experiencing major cardiovascular events such as myocardial infarction.
Revascularization typically involves one of two methods: coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). These strategies are crucial for cardiovascular care, greatly improving patients’ survival outcomes and offering them a better quality of life.
Board-certified cardiothoracic surgeon Dr. Shamini Parameswaran chooses the most appropriate procedure depending on factors such as the complexity of coronary lesions, patient comorbidities, and clinical presentation.
For Dr. Parameswaran, CABG is generally the best course of action for patients with severe or multi-vessel disease, providing robust revascularization and reducing mortality among high-risk individuals.
On the other hand, Dr. Parameswaran recommends PCI for less complex cases and acute presentations due to its comparatively minimally invasive nature. Technological advancements such as drug-eluting stents further reinforce the suitability of PCI for patients with relatively simple CAD.
Coronary Artery Bypass Grafting (CABG)
CABG addresses restricted blood flow caused by blocked arteries by using grafts from veins or other arteries. It is most often used in the following cases:
- Complex, multivessel coronary artery disease
- Left main coronary artery disease
- Diabetes or reduced left ventricular function
The grafts are typically taken from the internal mammary artery, which is chosen for its durability; the saphenous vein in the leg; or the radial artery in the arm.
Long-Term Survival Outcomes with CABG
CABG is known to reduce mortality rates among patients with extensive coronary artery disease and/or in patients with diabetes mellitus. The procedure can result in significant and sustained improvement in myocardial blood flow, helping preserve cardiac function.
CABG could also reduce the likelihood of recurrent angina and possibly decrease the necessity of repeat procedures compared to PCI.
Percutaneous Coronary Intervention (PCI)
PCI is a minimally invasive method that utilizes balloon angioplasty and stents to restore blood flow.
Surgeons such as Dr. Shamini Parameswaran recommend the procedure for patients with single or limited-vessel disease or those with acute coronary syndromes, such as heart attacks. The latter cases include myocardial infarction, wherein rapid intervention is often necessary.
PCI is also advisable for patients who aren’t ideal candidates for surgery.
The two methods used in PCI restore blood flow in different ways, although each requires only a minimally invasive procedure. In balloon angioplasty, surgeons insert a balloon into the affected artery and inflate it at the blockage site to widen the arterial pathway.
With stenting, interventional cardiologists insert a metal mesh tube which may be either bare-metal or a drug-eluting stent (DES). As with balloon angioplasty, the procedure results in the widening of the affected artery.
Long-Term Survival Outcomes with PCI
PCI can improve survival outcomes significantly, especially given the advances in DES. With the use of DES, many patients experience reduced occurrences of restenosis and require fewer repeat interventions.
For patients with less complex diseases, PCI offers comparable survival rates to CABG. However, patients with multivessel or high-complexity lesions may experience higher rates of restenosis and recurrent cardiovascular issues, making CABG the better option.
Hybrid Coronary Revascularization (HCR)
In the mid-1990s, hybrid coronary revascularization (HCR) was introduced as an alternative treatment for CAD. This hybrid approach combines the durability of CABG with the minimal invasiveness of PCI, essentially offering patients the best of both methods.
Depending on the complexity of the patient’s condition, surgeons may opt to employ CABG in one artery and PIC for another. This hybrid approach is best suited for patients with multi-vessel as well as localized disease, or those who are better suited for a minimally invasive procedure combined with PCI.
Long-Term Survival Outcomes with HCR
As with CABG and PCI, long-term survival outcomes with HCR depend on the patient, the coronary lesions to be treated, and how effectively the procedures are integrated.
In any case, HCR generally results in improved graft patency, reduced surgical trauma, and minimal complications, all of which can improve long-term survival rates.
Choosing Between CABG, PCI, and HCR
CABG and PCI‒and by extension, HCR‒have conclusively been shown to affect survival outcomes positively. However, it’s important to realize that their effectiveness is dependent on the patients and their disease characteristics.
When considering the most appropriate revascularization strategy to undertake, Dr. Shamini Parameswaran considers the complexity of coronary anatomy as determined by the patient’s SYNTAX score, comorbidities, such as diabetes or chronic kidney disease, and the patient’s age, functional capability, and preferences.
Dr. Parameswaran also emphasizes the importance of understanding the long-term implications of these techniques. This knowledge is crucial for the development of effective treatment plans and improving patient outcomes.
As technology advances and medical procedures improve, the influence of revascularization on survival outcomes will remain a core aspect of cardiovascular research and treatment.
For Dr. Parameswaran, collaborative decisions between patients, cardiologists, and surgeons are the most effective ways to ensure the utilization of the most appropriate technique, improve long-term survival, and ensure a better quality of life.