Coronary angioplasty vs bypass surgery in proximal left anterior descending artery stenosis

The points of view of the cardiac surgeon and the interventional cardiologist on their personal approach to the treatment of the significant lesions of the proximal left anterior descending coronary artery are still a matter of controversy. Two randomized studies have compared the efficacy of PTCA vs CABG in the treatment of patients with isolated proximal left anterior descending (LAD) coronary artery stenosis. After a mean follow-up of 3 years these studies concluded that the incidence of events was significantly reduced in the CABG group. However, this conclusion requires a cautious interpretation because of methodological limitations of these studies. On the other hand, a recent randomized study has shown a reduction in the restenosis rate when an intracoronary stent is electively implanted after PTCA in proximal LAD stenosis. Similarly, surgical modifications in material and in technical aspects will probably result in a reduction of the morbidity sometimes associated with surgical procedures. Presented with favourable anatomy, PTCA with elective stent implantation may be the initial option in the treatment of proximal LAD stenosis, especially if another revascularization procedure is contemplated in the future. However, CABG is preferred when the LAD lesion suggests a complicated anatomy (chronic obstructions, ostial lesions or proximal bifurcations with a significant diagonal). Depending on the particular results for both procedures in each Institution, an individual evaluation seems to be mandatory in the vast majority of patients.