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

Circulation. 2022;145:e18–e114. DOI: 10.1161/CIR.0000000000001038 January 18, 2022 e79 CLINICAL STATEMENTS AND GUIDELINES

reduced acute and long-term graft patency in such patients.33,34 Intimal tears, medial dissections, and increased intimal thickness are frequently found after radial artery catheterization,35 and greater intimal hyperplasia was noted in the radial artery in pathology studies after radial artery catheterization.34 The studies, which evaluated the integrity of the radial artery early after radial artery catheterization, were generally performed within 6 weeks of the radial artery procedure. The persistence of these abnormal findings in the radial artery in longer-term follow-up is uncertain. Given the increase in the use of radial access for coronary angiography and intervention, it would be important to know whether these pathological findings remain over time. Further research is needed to determine whether there is healing of the radial artery and, if so, whether the radial artery might be considered suitable for graft harvesting after a prespecified period of time that allows for resumption of normal endothelial integrity. 17.3.2. Completeness of Revascularization in Multivessel Disease In patients with multivessel disease, when feasible, operators often attempt to treat all vessels to allow for a complete revascularization. There are no randomized studies prospectively comparing planned complete versus incomplete revascularization in SIHD, but several observational studies have concluded that patients who undergo CABG or PCI have worse outcomes if major epicardial vessels with significant stenoses are not revascularized during the index procedure.36-41 In the SYNTAX trial, in which complete revascularization was attempted in all patients, patients who underwent CABG or PCI with incomplete revascularization had worse cardiovascular outcomes at long-term followup.42 Nevertheless, patients who have incomplete revascularization are more likely to have a greater burden of comorbidities, including older age, diabetes, renal failure, previous MI, lower left ventricular function, and more extensive and complex coronary anatomy, that may also impact the completeness of revascularization. The observational studies comparing patients who receive complete or incomplete revascularization cannot fully account for the underlying reasons why an operator might choose to revascularize only a limited area. It is reasonable to rationalize that complete revascularization to improve perfusion of as large an amount of myocardium as possible is a good strategy and likely improves patient outcomes. Nevertheless, the ISCH- EMIA trial, which encouraged complete revascularization (especially if the arteries supplied areas in which there was ischemia on stress testing), did not demonstrate improved cardiovascular outcomes with revascularization. As such, when considering multivessel PCI or additional bypass grafting during a CABG procedure, one must be mindful of the theoretical benefits of complete revascularization for the individual patient. RCTs are needed to examine the benefits of complete revascularization in SIHD, with trial designs that mimic the trials performed on patients with STEMI and multivessel disease.43

17.3.3. Hybrid Coronary Surgery The hybrid approach to coronary revascularization (which combines minimally invasive off-pump grafting of the LIMA to the LAD, with PCI of the remaining vessels) has gained increasing popularity in recent years, although it is still performed by few select centers in the United States.44 Small RCTs and observational studies with propensity-matching of hybrid revascularization versus conventional CABG45-47 have found similar rates of death, MI, stroke, and repeat revascularization. Unfortunately, the Hybrid Coronary Revascularization trial, a phase 3, large-scale, randomized trial designed to compare multivessel PCI with hybrid coronary surgery in patients with disease of the LAD and ≥1 additional stenoses, was terminated early because of low enrollment (ClinicalTrials.gov identifier: NCT03089398). For this reason, the role of hybrid surgery as an alternative to multivessel PCI for patients with multivessel disease involving the LAD remains unclear. Furthermore, the Hybrid Coronary Revascularization trial did not compare hybrid surgery as an alternative to traditional CABG and, as such, additional studies to evaluate the use of hybrid surgery in these circumstances are needed. Other areas in need of further research include the use of non-sternotomy coronary artery revascularization. 17.3.4. Revascularization Before Percutaneous Valve Procedures The presence of CAD in patients referred for TAVR is variable, with 15% to 81% of patients enrolled in the landmark trials of TAVR having obstructive CAD.48 Although the presence of CAD, particularly complex CAD, is associated with worse outcomes after TAVR,49 observational studies have not demonstrated improved outcomes when PCI is performed before TAVR.50 The RCT that evaluated TAVR versus surgical AVR advised that PCI be performed before TAVR in patients with proximal obstruction of large vessels.51 For this reason, PCI is often planned before valve procedures, and guidelines indicate that PCI may be reasonable in patients with severe disease of the proximal arteries.52 Nevertheless, this recommendation is based on limited data, and therefore, further research is needed to determine whether the routine use of PCI before percutaneous valve procedures improves outcomes. 17.3.5. Revascularization Before Organ Transplantation There are currently no RCTs evaluating the role of revascularization before solid organ transplantation, although

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