title: Optimal revascularization for complex coronary artery disease.
abstract: Patients with major or symptomatic coronary artery disease (CAD) commonly undergo revascularization--either with CABG surgery, which has been the mainstay of revascularization for more than half a century, or with percutaneous coronary intervention (PCI), which has become the more-commonly used strategy in the past decade. PCI has been tested in more randomized clinical trials than any other procedure in contemporary practice. In general, PCI is the preferred option for treating patients with simple coronary artery lesions and CABG surgery remains the standard of care for patients with complex CAD. Technical advancements in PCI and CABG surgery make comparisons of historical data for these strategies difficult. In this Review, we evaluate the evidence-based use of PCI and CABG surgery in treating patients with multivessel and unprotected left main stem disease and for specific patient groups, including those with diabetes mellitus, chronic heart failure, or chronic kidney disease. Finally, we highlight the available tools to aid decision-making, including clinical guidelines, risk scoring systems, and the role of the 'heart team'.
authors.affiliation: Department of Cardiovascular Science, University of Sheffield, Medical School, Beech Hill Road, Sheffield S10 2RX, UK.
authors.forename: Javaid
authors.initials: J
authors.lastname: Iqbal
authors.forename: Patrick W
authors.initials: PW
authors.lastname: Serruys
authors.forename: David P
authors.initials: DP
authors.lastname: Taggart
mesh_terms: D017023:Coronary Angiography; D001026:Coronary Artery Bypass / Q000009:adverse effects; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging / Q000601:surgery / Q000628:therapy*; D003661:Decision Support Techniques; D006801:Humans; D018579:Patient Selection; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects; D011237:Predictive Value of Tests; D012307:Risk Factors; D012720:Severity of Illness Index; D016896:Treatment Outcome
references.citation: J Am Coll Cardiol. 2011 Jan 11;57(2):128-37
references.pmid: 21211683
references.citation: Chin Med J (Engl). 2012 Mar;125(6):1000-4
references.pmid: 22613521
references.citation: Eur Heart J. 2009 Jul;30(13):1598-606
references.pmid: 19429632
references.citation: Circulation. 2010 Sep 14;122(11 Suppl):S48-52
references.pmid: 20837925
references.citation: Eur J Cardiothorac Surg. 2012 Apr;41(4):770-5; discussion 776
references.pmid: 22290908
references.citation: J Am Coll Cardiol. 2011 Feb 1;57(5):538-45
references.pmid: 21272743
references.citation: Ann Thorac Surg. 2006 Dec;82(6):1966-75
references.pmid: 17126093
references.citation: Circ J. 2009 Jul;73(7):1228-34
references.pmid: 19443956
references.citation: JAMA. 2004 Apr 21;291(15):1841-9
references.pmid: 15100202
references.citation: JAMA. 2009 Feb 4;301(5):487-8
references.pmid: 19190313
references.citation: Ann Thorac Surg. 1990 Feb;49(2):179-86; discussion 186-7
references.pmid: 2306138
references.citation: Eur J Cardiothorac Surg. 2013 May;43(5):1006-13
references.pmid: 23413014
references.citation: JAMA. 2011 Jul 6;306(1):53-61
references.pmid: 21730241
references.citation: Lancet. 2003 Jan 4;361(9351):13-20
references.pmid: 12517460
references.citation: N Engl J Med. 2010 Jul 8;363(2):136-46
references.pmid: 20554978
references.citation: J Thorac Cardiovasc Surg. 2009 Dec;138(6):1326-30
references.pmid: 19660378
references.citation: N Engl J Med. 2012 Dec 20;367(25):2375-84
references.pmid: 23121323
references.citation: J Thorac Cardiovasc Surg. 2008 Mar;135(3):503-11, 511.e1-3
references.pmid: 18329460
references.citation: J Am Coll Cardiol. 2008 Feb 5;51(5):538-45
references.pmid: 18237682
references.citation: Eur Heart J. 2012 May;33(10):1257-67
references.pmid: 21987177
references.citation: Heart. 2009 Jul;95(13):1061-6
references.pmid: 19304671
references.citation: N Engl J Med. 2009 Jun 11;360(24):2503-15
references.pmid: 19502645
references.citation: J Am Coll Cardiol. 2002 Apr 3;39(7):1151-8
references.pmid: 11923039
references.citation: N Engl J Med. 2012 Apr 19;366(16):1489-97
references.pmid: 22449296
references.citation: Lancet. 2006 Feb 18;367(9510):569-78
references.pmid: 16488800
references.citation: N Engl J Med. 2009 Jun 25;360(26):2705-18
references.pmid: 19553646
references.citation: J Am Coll Cardiol. 2010 Feb 2;55(5):432-40
references.pmid: 20117456
references.citation: Ann Thorac Surg. 2011 Jul;92(1):9-15; discussion 15-7
references.pmid: 21718825
references.citation: J Thorac Cardiovasc Surg. 2012 Apr;143(4):780-803
references.pmid: 22424518
references.citation: J Am Coll Cardiol. 2010 Jun 1;55(22):2435-45
references.pmid: 20359842
references.citation: Lancet. 1994 Aug 27;344(8922):563-70
references.pmid: 7914958
references.citation: J Am Coll Cardiol. 2011 Aug 9;58(7):692-703
references.pmid: 21816304
references.citation: Eur Heart J. 2007 Jul;28(13):1598-660
references.pmid: 17569677
references.citation: Arch Intern Med. 2012 Feb 27;172(4):312-9
references.pmid: 22371919
references.citation: N Engl J Med. 2011 May 5;364(18):1718-27
references.pmid: 21463149
references.citation: Circulation. 2008 Sep 9;118(11):1146-54
references.pmid: 18725490
references.citation: Circulation. 2005 Mar 22;111(11):1383-9
references.pmid: 15781749
references.citation: Nat Rev Cardiol. 2013 May;10(5):248-60
references.pmid: 23419901
references.citation: Lancet. 2001 Sep 15;358(9285):870-5
references.pmid: 11567701
references.citation: Eur Heart J. 2005 Apr;26(8):804-47
references.pmid: 15769784
references.citation: N Engl J Med. 2011 Apr 28;364(17):1607-16
references.pmid: 21463150
references.citation: Lancet. 2008 Feb 16;371(9612):559-68
references.pmid: 18280326
references.citation: Circulation. 2010 Sep 7;122(10):949-57
references.pmid: 20733102
references.citation: JAMA. 2006 Jun 7;295(21):2511-5
references.pmid: 16757723
references.citation: EuroIntervention. 2013 May 20;9(1):62-9
references.pmid: 23685296
references.citation: Lancet. 2004 Sep 18-24;364(9439):1045-53
references.pmid: 15380963
references.citation: Eur Heart J. 2012 May;33(10):1214-22
references.pmid: 22447805
references.citation: N Engl J Med. 2008 May 22;358(21):2205-17
references.pmid: 18499565
references.citation: Lancet. 2004 Oct 23-29;364(9444):1519-21
references.pmid: 15500897
references.citation: J Am Coll Cardiol. 2013 Jan 29;61(4):e78-e140
references.pmid: 23256914
references.citation: N Engl J Med. 2008 Jan 24;358(4):331-41
references.pmid: 18216353
references.citation: N Engl J Med. 2005 Dec 29;353(26):2758-68
references.pmid: 16382062
references.citation: Lancet. 2007 Feb 24;369(9562):667-78
references.pmid: 17321312
references.citation: Circulation. 2010 Jun 22;121(24):2645-53
references.pmid: 20530001
references.citation: Br Med Bull. 2013;106:193-211
references.pmid: 23532779
references.citation: Circulation. 2009 Dec 1;120(22):2271-306
references.pmid: 19923169
references.citation: EuroIntervention. 2011 Feb;6(7):838-45
references.pmid: 21252018
references.citation: BMJ. 2007 Mar 24;334(7594):617
references.pmid: 17337458
references.citation: J Am Coll Cardiol. 2008 Mar 4;51(9):885-92
references.pmid: 18308155
references.citation: Circulation. 2012 Jun 12;125(23):2827-35
references.pmid: 22592900
references.citation: Am J Med. 2009 Feb;122(2):152-61
references.pmid: 19185092
references.citation: Lancet. 2013 Jun 8;381(9882):1985-6
references.pmid: 23746900
references.citation: Circulation. 2006 May 30;113(21):2542-7
references.pmid: 16717151
references.citation: J Am Coll Cardiol. 2010 Jul 6;56(2):117-24
references.pmid: 20451344
references.citation: Am J Cardiol. 2006 Jul 1;98(1):54-9
references.pmid: 16784920
references.citation: Eur Heart J. 2012 Jan;33(1):16-25b
references.pmid: 22041548
references.citation: Lancet. 2012 Apr 14;379(9824):1393-402
references.pmid: 22445239
references.citation: Ann Intern Med. 2007 Nov 20;147(10):703-16
references.pmid: 17938385
references.citation: Circulation. 2012 Sep 11;126(11 Suppl 1):S164-9
references.pmid: 22965978
references.citation: Eur Heart J. 2013 Aug;34(32):2510-8
references.pmid: 23425523
references.citation: N Engl J Med. 2009 Jan 15;360(3):213-24
references.pmid: 19144937
references.citation: J Am Coll Cardiol. 2009 Feb 10;53(6):530-53
references.pmid: 19195618
references.citation: Perfusion. 2012 Mar;27(2):127-31
references.pmid: 22115880
references.citation: N Engl J Med. 2007 Apr 12;356(15):1503-16
references.pmid: 17387127
references.citation: JACC Cardiovasc Interv. 2012 Jul;5(7):718-27
references.pmid: 22814776
references.citation: JAMA. 2005 Jun 15;293(23):2908-17
references.pmid: 15956636
references.citation: Circulation. 2008 Dec 2;118(23):2374-81
references.pmid: 19029471
references.citation: Circulation. 2006 Jan 3;113(1):156-75
references.pmid: 16391169
references.citation: Eur Heart J. 2012 Dec;33(24):3105-13
references.pmid: 23103663
references.citation: J Am Coll Cardiol. 2010 Mar 16;55(11):1067-75
references.pmid: 20079596
references.citation: Circulation. 2010 Mar 2;121(8):973-8
references.pmid: 20159833
references.citation: Circulation. 2007 Jul 10;116(2):158-62
references.pmid: 17576862
references.citation: Ann Thorac Surg. 2008 Jul;86(1):29-34
references.pmid: 18573394
references.citation: Lancet. 2013 Feb 23;381(9867):629-38
references.pmid: 23439102
references.citation: Heart. 2003 Sep;89(9):967-70
references.pmid: 12922989
references.citation: N Engl J Med. 2009 Mar 5;360(10):961-72
references.pmid: 19228612
references.citation: JACC Cardiovasc Interv. 2008 Oct;1(5):483-91
references.pmid: 19463349
references.citation: Eur Heart J. 2009 Sep;30(17):2087-94
references.pmid: 19508996
references.citation: Circulation. 1975 Aug;52(2):275-85
references.pmid: 1080085
references.citation: Heart. 2012 May;98(10):799-805
references.pmid: 22422589
references.citation: Circulation. 2008 Mar 11;117(10):1283-91
references.pmid: 18268144
references.citation: Circulation. 1995 May 1;91(9):2335-44
references.pmid: 7729019
references.citation: Ann Thorac Surg. 2013 Aug;96(2):535-41
references.pmid: 23622702
references.citation: EuroIntervention. 2011 Oct 30;7(6):738-46, 1
references.pmid: 21947626
references.citation: Lancet. 2013 Feb 23;381(9867):639-50
references.pmid: 23439103
references.citation: EuroIntervention. 2012 Sep;8(5):599-606
references.pmid: 22995087
references.citation: JAMA. 2001 Jan 10;285(2):190-2
references.pmid: 11176812
references.citation: Heart Lung Circ. 2009 Jun;18(3):184-90
references.pmid: 19268632
references.citation: N Engl J Med. 2009 May 21;360(21):2176-90
references.pmid: 19332455
references.citation: JAMA. 2008 Apr 23;299(16):1903-13
references.pmid: 18430909
references.citation: Am J Cardiol. 2010 Aug 1;106(3):348-53
references.pmid: 20643244
references.citation: Eur J Cardiothorac Surg. 2009 Aug;36(2):312-21
references.pmid: 19608042
references.citation: JACC Cardiovasc Interv. 2012 Jul;5(7):801-2
references.pmid: 22814788
references.citation: N Engl J Med. 2012 Apr 19;366(16):1467-76
references.pmid: 22452338
references.citation: Ann Thorac Surg. 1997 Mar;63(3):869-78
references.pmid: 9066430
references.citation: Circulation. 2005 Sep 27;112(13):1992-2001
references.pmid: 16186436
references.citation: J Am Coll Cardiol. 2009 Oct 20;54(17):1576-88
references.pmid: 19833256
references.citation: Lancet. 2009 Mar 14;373(9667):911-8
references.pmid: 19286090
references.citation: N Engl J Med. 2013 Apr 11;368(15):1379-87
references.pmid: 23473396
references.citation: N Engl J Med. 2008 Jun 12;358(24):2641-2; author reply 2643-4
references.pmid: 18550881
references.citation: Eur Heart J. 2010 Oct;31(20):2501-55
references.pmid: 20802248
references.citation: Circ Cardiovasc Qual Outcomes. 2011 Sep;4(5):496-502
references.pmid: 21878670
references.citation: JACC Cardiovasc Interv. 2012 Mar;5(3):301-10
references.pmid: 22440496
references.citation: N Engl J Med. 2006 Dec 7;355(23):2395-407
references.pmid: 17105759
references.citation: J Am Coll Cardiol. 2009 Jun 23;53(25):2324-31
references.pmid: 19539141
references.citation: EuroIntervention. 2005 Aug;1(2):219-27
references.pmid: 19758907
references.citation: Circulation. 1988 Aug;78(2):486-502
references.pmid: 2969312
references.citation: N Engl J Med. 2012 Sep 13;367(11):991-1001
references.pmid: 22924638
references.citation: Circ J. 2012;76(3):721-8
references.pmid: 22240598
references.citation: Lancet. 2009 Apr 4;373(9670):1190-7
references.pmid: 19303634
references.citation: J Am Coll Cardiol. 2006 Apr 18;47(8):1530-7
references.pmid: 16630987
references.citation: Eur Heart J. 2010 Apr;31(8):943-57
references.pmid: 19933242
references.citation: Neth Heart J. 2010 Aug;18(7-8):348-54
references.pmid: 20730001
references.citation: Lancet. 1978 Feb 4;1(8058):263
references.pmid: 74678