Hybrid coronary revascularization

Abstract

Coronary artery bypass grafting (CABG) continues to remain the gold standard for management of patients with stable multivessel coronary artery disease (CAD) with moderate to high SYNTAX scores. The use of the left internal thoracic artery (LITA) as a graft to the left anterior descending (LAD) coronary artery has unarguably had the greatest positive impact on survival in patients undergoing revascularization even when performed through a minimally invasive approach. Percutaneous coronary intervention (PCI), which is regarded as a good alternative technique of revascularization to CABG for non-diabetic patients with low SYNTAX scores, is, however, still not equivalent to LITA-LAD grafting, at least with respect to repeat revascularization. This has led to the birth of a third modality of treating CAD called hybrid coronary revascularization (HCR), which primarily involves CABG to the LAD and PCI of other non-LAD targets. The main objective of this strategy is to achieve complete revascularization while reducing the risk of potential complications following conventional CABG to a minimum, but at the same time maintaining the survival benefit of the LITA-LAD graft. Several retrospective studies concerning HCR have been published in literature ever since its introduction in 1996. In contrast, very few small underpowered randomized controlled trials have been performed, which do not provide adequate evidence to enable the routine or frequent use of the hybrid procedures as an alternative strategy for at least a select group of patients. Thus, there remains an urgent need for large multicentre randomized trials that can demonstrate the safety and efficacy, the cost-effectiveness, and long-term results of HCR. The current review focuses on the indications, procedure strategy, the best available evidence, and the future perspectives of HCR as an evolving modality in the treatment of patients with CAD.