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Lawton et al 2021 ACC/AHA/SCAI Coronary Revascularization Guideline

January 18, 2022 Circulation. 2022;145:e18–e114. DOI: 10.1161/CIR.0000000000001038 e78

CLINICAL STATEMENTS AND GUIDELINES dial viability with derived benefit from revascularization, it remains unclear whether viability studies should be used to inform clinical practice, and if they are used, it remains unclear which method of assessment provides the most useful information.

There are currently insufficient data on the role of PCI in patients with left ventricular dysfunction to improve survival or cardiovascular outcomes. To address this gap in evidence, the ongoing REVIVED-BCIS2 (Percutaneous Revascularization for Ischemic Ventricular Dysfunction)19 study will evaluate the benefits of PCI versus medical therapy in reducing the combined endpoint of death or hospitalization for heart failure at 2 years’ follow-up. Additional studies are also currently under way, including the ISCHEMIA–Heart Failure Planning Study,20 which is expected to pave the way for a larger phase 3 trial of PCI in patients with systolic heart failure. 17.2.2. SCAD SCAD is increasingly recognized as a cause of ACS in young patients, particularly women, and is present in roughly one-fourth of women ≤50 years of age presenting with AMI.21 The management of SCAD has evolved over the years toward a more cautious use of PCI after various case series demonstrated low success rates and higher rates of complications with PCI for SCAD, as well as good long-term outcomes in conservatively treated patients.22 For this reason, expert consensus statements emphasize conservative care in most patients.23 However, managing patients with SCAD who have ongoing symptoms, hemodynamic instability, or severely compromised blood flow of an artery subtending a large amount of myocardium (ie, the proximal LAD or left main lesions) is particularly problematic, as conservative care may not be a good option. Further investigation therefore is needed to understand the ideal scenarios for proceeding with revascularization and the optimal techniques for revascularization in SCAD. 17.2.3. Coronary Artery Aneurysm Coronary artery aneurysms and fistulas are uncommon findings on coronary angiography, with a reported prevalence of 0.02% to 0.2%.24,25 Most patients with coronary artery aneurysms are asymptomatic, but coronary artery aneurysms can lead to ischemia, vessel thrombosis, fistula formation, or rupture.24-27 There are no randomized studies evaluating the most effective therapy for these patients. Case reports and case series have described various methods for repair of aneurysms or fistulas, including covered stenting, coil embolization, Amplatzer device implantation, and surgical bypass with exclusion of the aneurysm.24-27 Because many patients remain asymptomatic and treatments for aneurysms or fistulas are not well defined, information on the timing of intervention (with respect to size and/or symptoms) and the ideal approach to treatment (surgical excision versus percutaneous therapies) is strongly needed. 17.2.4. Myocardial Bridging Myocardial bridging occurs when there is systolic compression of a coronary artery because of a segmental intramyocardial course of the vessel, and it is seen in up to 25% of patients undergoing coronary angiography.28 Although most myocardial bridging is clinically insignificant, severe bridging has been inferred to produce myocardial ischemia, coronary thrombosis, AMI, and stress cardiomyopathy.28 In patients with ischemic pain and a myocardial bridge, provocative testing can be performed by measuring FFR under baseline conditions and during dobutamine stress or by obtaining positron emission tomographic imaging during adenosine vasodilator challenge.29 If a patient has evidence of severe ischemia and a significant myocardial bridge, surgical approaches are available; small studies have reported subsequent improvement in angina, as documented by the Seattle Angina Questionnaire.30 Although these data appear promising, the long-term risks and benefits of surgery for myocardial bridging are uncertain, and larger studies are needed to define best practices in these circumstances.

17.2.5. Treatment of Graft Failure Robust data are also lacking for recommendations for clinical situations that include acute graft failure after CABG, the percutaneous treatment of significant arterial graft disease after CABG, and percutaneous interventions via an arterial graft after CABG. Such circumstances warrant discussion with a Heart Team and further investigation. 17.2.6. Antiplatelet Therapy in Patients With ACS After CABG With an Indication for Anticoagulation Although antiplatelet therapy in patients with atrial fibrillation who are on anticoagulation after PCI is detailed in Section 14.5., there are no data to inform the treatment of patients after ACS who undergo CABG and also have an indication for anticoagulation (atrial fibrillation or mechanical valve). Care in such patients requires further study and careful consideration of bleeding risks, recurrent ischemic events, graft patency, and risk of thromboembolic events.

17.3 Revascularization Considerations

17.3.1. Use of the Radial Artery for a Conduit After Radial Artery Catheterization The number of patients undergoing radial artery catheterization has increased exponentially over the years.31 Some patients undergoing radial artery catheterization will ultimately require CABG. In patients undergoing CABG, the radial artery is the preferred conduit after the use of the LIMA.32 However, if the radial artery has been manipulated (eg, for access to perform coronary angiography or intervention), there is informal agreement among surgeons to generally avoid the use of this artery as a conduit for grafting, because of the findings of

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