Coronary revascularization

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Anahita Deylamsalehi, M.D.[2]


Coronary revascularization is one of the most commonly used surgical procedures worldwide. Currently, coronary revascularization has three techniques including, percutaneous coronary intervention (PCI), coronary artery bypass surgery (CABG), and hybrid coronary revascularization. CABG is one of the most common techniques with an overall of more than 20 million operations performed. Treatment decisions regarding coronary revascularization should be done regardless of sex, race, and ethnicity. Decision regarding coronary revascularization must be affected by coronary anatomy of patient, and the percentage of stenosis. Based on ACC 2021 guideline, coronary angiography is still the default method to determine coronary anatomy and stenosis degree. Furthermore, significant stenosis could be described as a estimated diameter stenosis more than 70% for non-left main disease, or more than 50% for left main disease. It is recommended to consider more investigations for stenosis more than 40% but less than 69%. Although the lesion's length can affect the ischemia severity, there are no standard cutoffs for the length of the lesions when severe stenosis is determined. Furthermore, the presence of other comorbidities can affect decision-making. Although many indications are the same for performing either PCI or CABG, these two procedures have inherently different mechanisms. While PCI mitigates an obstruction, it can not prevent plaque progression or rupture in other involved segments of the artery, on the other hand, CABG is able to prevent future ischemic insults caused by plaque progression or rupture in other involved segments of the artery. Most studies report the same outcome with PCI and CABG, but there is a number of reports that favor CABG over PCI. 2021 ACA revascularization guideline published many recommendation for coronary revascularization among specific patients, such as those with diabetes, or chronic kidney disease, and elderlies, pregnants.

Historical Perspective


Coronary revascularization may refer to;


Coronary Anatomy *Left main disease
*Multivessel disease
*Complicated anatomy (such as bifurcation disease, and high SYNTAX score
Comorbidities *Coagulopathy
*Valvular heart disease
*Systolic dysfunction
*End-stage renal disease
*Aortic aneurysm
*Calcified aorta
*Chronic obstructive pulmonary disease
*History of cerebral stroke
*Debilitating neurological disorders
*Cirrhosis/liver disease
Procedure *Access site for percutaneous coronary intervention (PCI)
*Risk of surgery
*Local and regional clinical outcomes
*Risk of percutaneous coronary intervention (PCI)
Patient *Patient preferences, religion believes, education, and knowledge
*Incompliant to dual antiplatelet therapy
*Patient social supports
*Unstable presentation or shock

Coronary Anatomy

Coronary Revascularization Comparison to Medical Therapy

What Procedure to Choose?

Angiographic Characteristics Contributing to Increasing Complexity of Coronary Artery Disease
Multivessel disease
Left main or proximal left anterior descending artery lesion
Chronic total occlusion
Trifurcation lesion
Complex bifurcation lesion
Heavy calcification
Severe tortuosity
Aorto-ostial stenosis
Diffusely diseased and narrowed segments distal to the lesion
Thrombotic lesion
Lesion length >20 mm

STEMI/Ischemia symptoms
Symptoms started started less than 12 hours
Symptoms started equal or more than 12 hours
Is PCI feasible?
Cardiogenic shock or heart failure
Ongoing ischemia? Heart failure? Electrolyte disturbance?
Onset of symptoms within 12-24 hours?
Totally occluded artery for longer than 24 hours without symptoms or ischemia
Is PCI feasible?
Primary PCICABG (if large area of myocardium is involved)
Primary PCI
No benefit in PCI
Primary PCI

Fractional flow reserve and instantaneous wave-Free Ratio

ACA 2021 Guidline Recommendations for Specific Patients


Class 1 Recommendation, Level of Evidence: A[4]
CABG with a LIMA to the LAD can reduce mortality and repeat revascularizations compared with PCI in diabetic patients who have multivessel coronary artery disease with LAD involvement and are appropriate candidates.
Class 2a Recommendation, Level of Evidence: B-NR [4]
PCI can be chosen to reduce long-term ischemic outcomes in diabetic patients with multivessel coronary artery disease and poor surgery candidacy (only when there is an indication for revascularization and patient preferences are considered.
Class 2b Recommendation, Level of Evidence: B-R [4]
PCI can decrease major adverse cardiovascular outcomes as an alternative to CABG in diabetic patients who have LAD stenosis and low to intermediate CAD complexity in other arteries.

Patients with Previous CABG

Class 2a Recommendation, Level of Evidence: B-NR[4]
PCI is preferred over CABG in a patient with a previous CABG history and a patent internal thoracic artery (LIMA) to LAD who requires revascularization again (only if feasible).
Class 2a Recommendation, Level of Evidence: C-LD[4]
CABG is preferred in a patient with a previous CABG history and refractory angina that is attributable to LAD disease when the internal mammary artery can be used.
Class 2b Recommendation, Level of Evidence: B-NR[4]
CABG is preferred in a patient with a previous CABG history and complex coronary artery disease when the internal mammary artery can be used.

Non Adherence to Dual Antiplatelet Therapy

Class 2a Recommendation, Level of Evidence: B-NR[4]
CABG is preferred over PCI in patients with multivessel coronary artery disease who are not able to be adherent to dual antiplatelet therapy.

Pregnant Patients

Class 2a Recommendation, Level of Evidence: C-LD[4]


Class 1 Recommendation, Level of Evidence: B-NR[4]
For choosing the appropriate vascularization strategy for elderies (older than 75) is it essential to consider their preferences, life expendency, cognitive function.

Patients with Chronic Kidney Disease

Class 1 Recommendation, Level of Evidence: C-LD[4]
Consider the risk of contrast-induced acute kidney injury in patients with chronic kidney disease who require contrast media injection for coronary angiography and minimize it.
Class 1 Recommendation, Level of Evidence: C-EO[4]
Coronary angiography and revascularization are recommended for chronic kidney disease patients with ST elevation myocardial infarction (consider and minimize acute kidney injury).
Class 2a Recommendation, Level of Evidence: B-NR[4]
Coronary angiography and revascularization are recommended for chronic kidney disease patients with high risk non-ST elevation myocardial infarction (consider and minimize acute kidney injury).
Class 2a Recommendation, Level of Evidence: B-NR[4]
Weigh the risk of coronary angiography and revascularization against the benefits of them for chronic kidney disease patients with low risk non-ST elevation myocardial infarction.
Class 2a Recommendation, Level of Evidence: B-NR[4]
Coronary angiography and revascularization are not recommended as a routine for chronic kidney disease patients with non-ST elevation myocardial infarction who are stable and asymptomatic.
Evaluate the risk of AKI due to contrast before performing the procedure
Keep the patient hydrated
Minimize contrast exposure
Pretreat with high-intensity statins
Choose radical access if it is feasible
Avoid using N-acetyl-L-cysteine for contrast-induced AKI prevention
If it is feasible delay CABG over 24 hours after angiography
Avoid prophylactic renal replacement therapy

Before Non-Cardiac Surgery

Class of Recommendation: No Benefit, Level of Evidence: B-R[4]
Routine prophylactic revascularization is not recommended in patients with non–left main or noncomplex coronary artery disease who need a non-cardiac surgery in order to only reduce the risk of death or cardiovascular events.

Ventricular Arrythmia

Class 1 Recommendation, Level of Evidence: B-NR[4]
Revascularization of significant coronary artery disease is recommended to increase survival in patients with ventricular fibrillation, polymorphic ventricular tachycardia, and cardiac arrest.
Class of Recommendation: No Benefit, Level of Evidence: C-LD[4]
If a coronary artery disease patient is suspected to suffer from scar-mediated sustained monomorphic ventricular tachycardia, revascularization is not recommended in order to prevent recurrent ventricular tachycardia.

Spontaneous Coronary Artery Dissection

Class 2b Recommendation, Level of Evidence: C-LD[4]
Revascularization can be considered in patients with spontaneous coronary artery dissection who are either hemodynamically unstable or still experiencing ischemia in spite of conservative therapy.
Class 3 Recommendation: HARM, Level of Evidence: C-LD[4]
Avoid routine revascularization in patients with spontaneous coronary artery dissection.

Patients With Cardiac Allografts

Class 2a Recommendation, Level of Evidence: C-LD[4]
PCI is reasonable to be performed in patients with cardiac allograft vasculopathy who has severe, proximal, and discrete coronary lesions.



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