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Page 6 of 10 Gacad et al. Vessel Plus 2019;3:28 I http://dx.doi.org/10.20517/2574-1209.2019.011

Figure 2. A proposed clinical-decision making flowchart with Hybrid Coronary Revascularization implementation. PCI: percutaneous
coronary intervention; CABG: coronary artery bypass graft; STEMI: ST-elevation myocardial infarction; NSTEMI: non-ST elevation
myocardial infarction

PRAGMATIC HCR
The 1-stage approach to conventional HCR requires a hybrid OR that is only available in one third
[20]
of hospitals in the United States . The 1-stage approach also requires a close collaboration between
interventional cardiologists and cardio-thoracic surgeons. Such collaboration is common for a trans-
catheter aortic valve implantation procedure but is not common practice for the management of CAD
[82]
patients . The major aim of HCR is to provide CAD patients with the long-lasting beneficial outcome
that LIMA affords and the complete revascularization including attention to chronic total occlusion that
endovascular stenting allows [83-85] .

HCR is a most suited form of revascularization for patients with mCAD and low to intermediate
SYNTAX score. Patients with mCAD and high SYNTAX score are better served by CABG surgery with
[12]
implantation of multi arterial conduits and when needed SVG . A more pragmatic approach to HCR
than that underlined in above-mentioned protocols is likely to facilitate its adoption by interventional
cardiologists and cardio-thoracic surgeons. The 2-stage approach to HCR appears to be eminently more
practical than the 1-stage approach in most American medical centers. CABG of LIMA to LAD may
be conveniently performed through sternotomy as CT surgeons are more familiar with the sternotomy
than the thoracotomy approach for CABG. An interval of 2-3 days between surgical and endovascular
revascularization allows times for the inflammatory response to surgery to subside and for control of peri-
operative bleeding before initiation of dual anti-platelet therapy. The 1-stage approach to HCR and the
practice of HCR in patients with critical obstructions of non-LAD arteries will await encouraging results of
the 2-stage approach to HCR.

CONCLUSION
In the age of PCI, HCR combines the known benefit of LIMA to LAD grafting with the minimally
invasive approach of stenting non-LAD territories. The wide acceptance of HCR by the cardiovascular
community will require demonstration of safety and long-lasting benefit on cardiovascular outcomes. A
more pragmatic approach than currently outlined may help interventional cardiologists and cardiothoracic
surgeons gain experience with dual surgical/endovascular coronary revascularization.