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Page 4 of 10 Gacad et al. Vessel Plus 2019;3:28 I http://dx.doi.org/10.20517/2574-1209.2019.011

2
1
Table 1. Rates of drug eluting stent target lesion revascularization , saphenous vein graft failure ,
and LIMA-LAD arterial graft failure 2
1-year 5-year 10-year
1st generation DES- Paclitaxel (PES)/Sirolimus (SES) 3.97% 3 11.50% 4 16.4% 6
2nd generation DES- Everolimus (EES) 6.03% 3 7.53% 4 14.8% 6
Saphenous vein graft 2.1%-19% 5 14%-25% 5 39% 8
LIMA-LAD graft 3.4% 7 11.9% 7 11.9% 7
1 Drug eluting stent occlusion was measured by rates of target lesion revascularization; saphenous vein graft patency was measured
2
3
by angiographic evidence of vessel occlusion; 1-year data from a meta-analysis comparing 1st generation DES (PES and SES) to 2nd
generation DES (EES) [57] 4 [16] 5
; 1-
; 5-year data from a meta-analysis comparing 1st generation DES (PES) to 2nd generation DES (EES)
year and 5-year data from a meta-analysis comparing saphenous vein vs. arterial conduits [42] . It should be noted that definitions of graft
6
failure varied between the different studies; 10-year data from a multicenter European randomized trial, which used pre-planned repeat
angiography to reassess in-stent restenosis [86] 7,8
; rates of SVG and LIMA-LAD were determined via angiography in their respective
studies [15,87]
As an attempt to reduce ischemic time and practical considerations of immediate revascularization after a
[64]
diagnostic angiogram, PCI has become the most frequent revascularization strategy . There is a scarcity of
data directly comparing DES with CABG in the setting of ACS, which mostly consists of subgroup analysis
of larger PCI vs. CABG studies. A recent meta-analysis of these subgroups found reduced myocardial
infarction (MI) incidence with CABG (3.8%) when compared to DES (7.5%) after non-ST elevation MI
[65]
(NSTEMI), with similar rates of mortality (8.7% vs. 10.8%, P = 0.248) and stroke (2.6% vs. 2.8%, P = 0.788) .
Recent PCI mortality data have favored immediate complete revascularization (the coronary intervention
of both culprit and non-culprit obstructive stenoses) rather than culprit-lesion only PCI followed by
staged-PCI of non-critical stenosis [66,67] . When compared to culprit-only PCI, complete revascularization
[68]
has shown similar rates of contrast-induced nephropathy .

In summary, revascularization methods in the setting of acute coronary syndrome skew toward PCI in part
due mortality benefit from decreased ischemic time. However, in head-to-head analysis there is a modest
reduced subsequent MI benefit for CABG.

CONVENTIONAL HCR
HCR consists of 2 separate procedures: surgical CABG surgery with a LIMA graft to the LAD and PCI
with implantation of 2nd generation DES to diseased non-LAD coronary arteries. The 2 procedures can be
performed back to back in a 1-stage approach or on different days in a 2-stage approach [Table 2 and Figure 1].

The 1-stage approach is generally performed in a hybrid operating room (OR) with the LIMA graft being
first anastomosed to the LAD followed by PCI with endovascular implantation of 2nd generation DES
in non-LAD arteries [19,69-71] . The surgical LIMA to LAD surgical anastomosis is commonly performed
through an anterolateral thoracotomy at the level of the 4-5th intercostal space. The thoracotomy approach
has the advantage of shorter ventilation time and post-operative length of stay over a conventional
CABG sternotomy [72-75] . However, thoracotomy may be associated with increased pain levels in the
immediate post-operative period [70,76] . The use of cardiopulmonary bypass is commonly left to operator
preference. Percutaneous endovascular revascularization of diseased non-LAD arteries is performed after
[20]
administration of loading dose of anti-platelet agents . The advantage of the 1-stage approach is the
verification and possible repair of a defective LIMA-LAD anastomosis before initiation of anti-platelet
therapy. Its disadvantage is the need for a hybrid OR.

[71]
The 2-stage approach encompasses an interval of 1-2 days between surgical and endovascular CAR . It
allows for control of bleeding in the post-operative period before initiation of anti-platelet therapy and does