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Is bypass surgery still benefited for proximal left anterior descending artery stenosis?

The proximal left anterior descending artery (PLAD) has been considered an anatomical lesion of coronary artery bypass graft (CABG) surgery derived from a survival benefit relative to medical therapy. However, the advances in equipment and technique in percutaneous coronary intervention (PCI) induced the PLAD as an attractive target. The relative benefit PCI over CABG was accompanied by speed of reperfusion and low periprocedural morbidity. On the contrary, CABG was more benefited by better protection of ischemic territories rather than simply treating the lesion and greater durability of grafted conduit than coronary stents. The patency rate of left internal mammary artery (LIMA) was over 90% at 15 years [1]. However, introduction of drug-eluting stent (DES) has improved outcomes of PCI in which the recurrence rate was significantly reduced. In the SIRIUS trial, in-stent restenosis did not occur with sirolimuseluting stent and was 38% with bare-metal stent [2]. The incidence of target vessel revascularization in a recent large registry was 7.9% after sirolimus-eluting stent implantation in 2,274 patients with PLAD stenosis [3]. The other DES coated with paclitaxel also showed a low repeat revascularization rate for LAD stenosis [4]. Toutouzas et al., recently performed a retrospective study comparing the outcomes of PCI versus CABG for 257 patients with PLAD stenosis [5]. All patients treated with CABG received a LIMA graft for conduit. The incidence of in-hospital compilation was significantly lower in patients treated with DES. Over the mean follow-up of 18 months, the incidence of death or myocardial infarction was comparably low in the two treatments. Also, the two groups had a comparable incidence of repeat revascularization. Consequently, overall adverse events rate was not statistically different. This study supported the previous retrospective nonrandomized studies showing comparable long-term outcomes of DES versus CABG for PLAD stenosis. Although several registries showed a comparable long-term efficacy of both DES and CABG for PLAD stenosis, the opinion of doctors for such a lesion is still conflicting because of the following: