Controversies in myocardial revascularization: coronary artery surgery for single-vessel disease.
In the early years of coronary artery bypass surgery, patients with single-vessel disease dominated the operative groups because of the presumed lower operative risk for a new surgical procedure. Of these patients, presence of disease in the anterior descending artery was particularly selected because the natural history studies of single-vessel coronary artery disease had identified that cohort as carrying a poorer long-term prognosis with medical treatment. Although subsequent surgical studies showed the best results with operative revascularization were obtained with anterior descending disease, especially when the internal mammary artery was used as the conduit for revascularization, comparison of the surgical results to medical treatment in the randomized trials usually failed to yield a statistically significant advantage for surgical intervention. The results were obviously better for surgical compared with medical treatment if only anterior descending coronary disease was evaluated. In the late 1970s the advent of PTCA as a less invasive and expensive intervention brought new attention to patients with single-vessel coronary disease. Although inhospital success rates were good for PTCA patients with single-vessel disease, and continued to improve with the evolving technology, few reports truly evaluated the later results of the procedure. Of those that assessed the longer-term results, all identified a significant requirement for reintervention. As several studies began to evaluate the longer-term effects of PTCA compared with operative revascularization, the failure of PTCA to achieve an event-free interval, even with single-vessel coronary disease, became increasingly apparent.(ABSTRACT TRUNCATED AT 250 WORDS)
Department of Surgery, Massachusetts General Hospital, Boston 02144.
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Akins
D000368:Aged; D015906:Angioplasty, Balloon, Coronary; D001026:Coronary Artery Bypass; D003327:Coronary Disease / Q000453:epidemiology / Q000601:surgery*; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D016032:Randomized Controlled Trials as Topic; D012086:Reoperation; D012307:Risk Factors; D016019:Survival Analysis; D015996:Survival Rate