Recurrent ischaemia leading to angina, repeat revascularisation and cardiac mortality is more common after PTCA than with CABG, because PTCA more commonly results in incomplete revascularisation and an appreciable risk of ischaemia. Incomplete revascularisation is an independent predictor of adverse outcome (Cowley etal., 1993). Whilst several trials have found CABG to be superior to PTCA in diabetes (O'Keefe etal., 1998; Weintraub etal., 1998, 1999), whereas one other trial (Halon etal., 2000) and the Duke University registry (Barsness etal., 1997) did not. Overall, surgical revascularisation for multivessel CHD in diabetic patients, particularly in insulin-treated patients, is associated with a survival advantage compared with PTCA.
However, studies with long-term follow-up beyond 10 years have indicated that the survival benefits of surgery may be attenuated. van Domburg etal. (2002) reported on 1041 surgically treated patients (8% diabetes) and 704 (11%) medically treated patients who underwent first PTCA or CABG at the Thorax Centre in Rotterdam. During the first 10 years after revascularisation, survival and revascularisation rates in diabetic and non-diabetic patients who had multivessel disease were better in surgically treated patients, compared to those who underwent PTCA. On follow-up at 10-20 years, revascularisation rates in surgically treated patients were higher whereas survival was similar in both groups (Figure 3.2).
Thus, whilst restenosis rates and survival are poorer in diabetic patients undergoing PTCA compared to those undergoing surgery, this is not the case for non-diabetic patients with multivessel disease, and these differences appear to dissipate with follow-up in the longer term, most likely due to late graft failure.
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