Revaskularisation bei 3–Gefäßerkrankung und Hauptstammstenosen – Ist die Bypass–OP der PCI wirklich überlegen?

Bislang gilt die Bypassoperation als die Therapieoption der Wahl für Patienten mit koronarer 3–Gefäßerkrankung und/oder Hauptstammstenose. Neue Stent– und Interventionstechnologien (PCI) fordern die Operation jedoch seit wenigen Jahren auch für diese prognostisch relevanten Formen der KHK heraus. In den derzeit verfügbaren randomisierten Vergleichsstudien zeigt sich eine Überlegenheit der Operation einheitlich nur bezüglich der Notwendigkeit einer erneuten Koronarintervention, während Überlebensraten und Myokardinfarktrate nur einen Trend zugunsten der Operation ergeben und die Schlaganfallrate sogar signifikant für die PCI spricht. Größere Registerdaten belegen hingegen auch bei diesen Formen der KHK weiterhin einen Überlebensvorteil der Operation gegenüber der PCI.

Nach den Ergebnissen der größten hierzu durchgeführten Studie (SYNTAX–Studie) zeichnet sich ein Trend ab, dass die PCI bei Patienten mit weniger komplexer KHK durchaus schon heute eine vergleichbare Behandlungsoption darstellt, wohingegen Patienten mit komplexer Koronarpathologie unverändert bevorzugt von der Bypassoperation profitieren. Langzeitergebnisse wie auch aktuelle Leitliniendiskussionen müssen jedoch für eine abschließende Bewertung abgewartet werden.

Coronary artery bypass graft surgery (CABG) is considered to be the standard of care for patients with prognostically relevant pattern of coronary artery disease. However, new stent devices and improvements in percutaneous coronary intervention (PCI) technologies during the last years challenge CABG in the treatment of coronary three–vessel disease and/or left main stem stenosis. To date randomized trial data demonstrated comparable results regarding procedural and mid–term survival as well as the incidence of myocardial infarction while cerebrovascular adverse event rates were lower in PCI patients. In contrast, all studies demonstrated consistently a significantly higher rate of repeat coronary revascularization when using PCI. Nevertheless, registry real world data demonstrated also a survival benefit when using CABG as the primary treatment option.

Recently 2–year results of the largest comparative randomized trial were available. These data demonstrated comparably good results in patients with less complex coronary artery disease between PCI and CABG, while patients with more complex coronary pathologies had better results by surgical intervention. However, current guidelines discussion and long–term results remain to be seen.

Key words

PCI - CABG - left main stenosis - multi–vessel disease - DES

Literatur

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