Stent oder MIDCAB? – Therapie der isolierten proximalen LAD–Stenose

Die isolierte proximale left anterior descending (LAD) Koronararterienstenose ist von prognostischer Relevanz und bei der Revaskularisation mittels perkutaner Koronarintervention (PCI) oder Bypassoperation ergeben sich spezifische Besonderheiten. In der vorliegenden Übersicht werden beide Revaskularisationsverfahren, die PCI mit Stents und die minimal invasive direkte Bypasschirurgie (MIDCAB–OP) beschrieben sowie die derzeitige Datenlage beleuchtet. Während die PCI mit Bare–Metal–Stents in Bezug auf erneute Zielgefäßrevaskularisationen der MIDCAB–OP bei gleichen Ergebnissen für Vermeidung von Tod oder Myokardinfarkt unterlegen war, konnten mit Einführung von Drug–eluting–Stents für die PCI vergleichbare Ergebnisse zur MIDCAB–OP erreicht werden.

Isolated proximal left anterior descending (LAD) coronary artery stenosis is of prognostic relevance and proximal stenosis location carries specific specialties for revascularization either by percutaneous coronary intervention (PCI) or coronary artery bypass grafting. In the following overview both revascularization strategies, PCI plus stenting and minimally invasive direct coronary artery bypass grafting (MIDCAB) are described. In addition, the current evidence is reviewed. PCI plus bare–metal stenting was inferior to MIDCAB surgery with respect to target vessel revascularization rates with similar results for freedom from death and infarction. Since the introduction of drug–eluting stents similar results can be obtained with PCI in comparison to MIDCAB surgery.

Atherosclerosis - bypass - coronary artery disease - restenosis - drug–eluting stents - coronary artery disease

Literatur

• 1 Varnauskas E.. Twelve–year follow–up of survival in the randomized European Coronary Surgery Study.  N Engl J Med. 1988;  319 332-337
• 2 Hueb WA, Bellotti G, de SA Oliveira. et al. . The Medicine, Angioplasty or Surgery Study (MASS): a prospective, randomized trial of medical therapy, balloon angioplasty or bypass surgery for single proximal left anterior descending artery stenoses.  J Am Coll Cardiol. 1995;  26 1600-1605
• 3 Parisi AF, Folland ED, Hartigan P.. A comparison of angioplasty with medical therapy in the treatment of single–vessel coronary artery disease. Veterans Affairs ACME Investigators.  N Engl J Med. 1992;  326 10-16
• 4 Diegeler A, Thiele H, Falk V. et al. . Comparison of stenting with minimally invasive bypass surgery for stenosis of the left anterior descending coronary artery.  N Engl J Med. 2002;  347 561-566
• 5 Khat AA, Hamm CW, Senges J. et al. . Sirolimus–eluting stent treatment for isolated proximal left anterior descending artery stenoses.  Z Kardiol. 2005;  94 187-192
• 6 Sawhney N, Moses JW, Leon MB. et al. . Treatment of left anterior descending coronary artery disease with sirolimus–eluting stents.  Circulation. 2004;  110 374-379
• 7 Dangas G, Ellis SG, Shlofmitz R. et al. . Outcomes of paclitaxel–eluting stent implantation in patients with stenosis of the left anterior descending coronary artery.  J Am Coll Cardiol. 2005;  45 1186-1192
• 8 Kolessov VI.. Mammary artery–coronary artery anastomosis as method of treatment for angina pectoris.  J Thorac Cardiovasc Surg. 1967;  54 535-544
• 9 Paparella D, Yau TM, Young E.. Cardiopulmonary bypass induced inflammation: pathophysiology and treatment. An update.  Eur J Cardiothorac Surg. 2002;  21 232-244
• 10 Diegeler A, Falk V, Matin M. et al. . Minimally invasive coronary artery bypass grafting without cardiopulmonary bypass: early experience and follow–up.  Ann Thorac Surg. 1998;  66 1022-1025
• 11 Diegeler A, Hirsch R, Schneider F. et al. . Neuromonitoring and neurocognitive outcome in off–pump versus conventional bypass surgery.  Ann Thorac Surg. 2000;  69 1162-1166
• 12 Mack MJ, Magovern JA, Acuff TA. et al. . Results of graft patency by immediate angiography in minimally invasive coronary artery surgery.  Ann Thorac Surg. 1999;  68 389-390
• 13 Jaffery Z, Kowalski M, Weaver WD, Khanal S.. A meta–analysis of randomized control trials comparing minimally invasive direct coronary bypass grafting versus percutaneous coronary intervention for stenosis of the proximal left anterior descending artery.  Eur J Cardiothorac Surg. 2007;  31 691-697
• 14 Thiele H, Oettel S, Jacobs S. et al. . Comparison of bare–metal stenting with minimally invasive bypass surgery for stenosis of the left anterior descending coronary artery. A 5 year follow–up.  Circulation. 2005;  112 3445-3450
• 15 Thiele H, Neumann–Schniedewind P, Jacobs S. et al. . Randomized comparison of minimally invasive direct coronary artery bypass surgery versus sirolimus–eluting stenting in isolated proximal left anterior descending coronary artery stenosis.  J Am Coll Cardiol. 2009;  53 2324-2331

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