Complete Versus Incomplete Revascularization With Coronary Artery Bypass Graft or Percutaneous Intervention in Stable Coronary Artery Disease

In patients who have multivessel but stable coronary artery disease (CAD), the perceived advantages of complete revascularization (CR) over incomplete revascularization (IR) are intuitively logical and have been the impetus to perform CR whenever feasible. These advantages were suggested by early studies in patients with 3-vessel CAD who underwent coronary artery bypass graft (CABG) demonstrating a survival benefit of patients with CR compared with those with IR.1–4 Nonetheless, in practice, the variations in severity of the coronary anatomy as well as the patient’s clinical status often precludes CR resulting in a higher frequency of IR in patients with multivessel disease. For example, in the SYNTAX (SYNergy between PCI with TAXus and Cardiac Surgery) trial, patients randomized to percutaneous intervention (PCI)5 had CR in only 56.7% even when CR was intended and in Bypass Angioplasty Revascularization Investigation (BARI) this was 56%.6 A critical review of the literature demonstrates the complexity of the issues and poses several unanswered questions (Table 1).View this table:Table 1. Unanswered QuestionsIn the current era of significantly improved medical therapy (primary and secondary prevention) of CAD as well as the increasing use of sophisticated invasive and noninvasive testing of the physiological significance of coronary artery stenoses, both surgeons and cardiologists have an arsenal of diagnostic tools at hand that may guide decisions in selecting revascularization strategies. This review provides a contemporary overview of the currently available literature in the field and proposes an evidence-based approach for patients with severe CAD and stable angina undergoing revascularization. The Missing Universal DefinitionThe dilemma of comparing outcomes after CR and IR begins with the lack of universal definitions. There are considerable differences between complete/incomplete anatomic and functional/physiological revascularization. Ong and Serruys8 reviewed comprehensively past definitions of CR used in different trials (Table 2).View this table:Table 2. Summary of Definitions for Complete Revascularization …