Selection of Revascularization Method

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Diabetics being considered for revascularization are older than nondiabetics, more likely to be female and to have more cardiac morbidity (prior MI, multile-sion, multivessel, and diffuse coronary disease, and heart failure) and more comorbidity (renal insufficiency, peripheral vascular and pulmonary disease). Unfortunately, the available data are inadequate to accurately guide the clinician in the selection of optimal revascularization therapy in this patient population. What does seem clear is that balloon angioplasty alone is associated with decreased survival compared with CABG when used in patients with multivessel disease (especially when >4 lesions are treated), and very preliminary results from ARTS also recommend caution with stenting in this subgroup. As the number and complexity of lesions increase, the relative value of CABG increases. When singlelesion disease is present, CABG is rarely selected (exceptions being left main, ostial or proximal LAD unfavorable for PCI, or long or complex LAD lesions). Until more complete long-term outcome data are available from ARTS, SOS, and other trials comparing stents and CABG, physicians must make revascularization decisions in patients with multivessel disease based on incomplete study data and clinical experience. When PCI is selected, utilization of stents and abciximab provide significant advantages. CABG is indicated for many patients with multivessel disease involving the proximal LAD who are suitable for LIMALAD graft (see Fig. 10). With increasing lesion complexity and number, left ventricular and renal dysfunction, and insulin requirements, CABG is favored. The primary advantage of surgery is the replacement of an atherosclerotic-prone coronary arterial segment with an arterial conduit, the LIMA, which is resistant to atherosclerosis even in the diabetic patient (57). PCI is commonly used in multivessel disease with two-vessel involvement where stenting is feasible, the LAD is spared, <4 lesions are present, or when a culprit lesion strategy seems best due to comorbidity, advanced age, or poor distal vessels making CABG unattractive, or when use of the IMA is not feasible. The presence of anginal symptoms that would be expected to return should restenosis occur is an asset in diabetics undergoing PCI. Careful follow-up of diabetic patients undergoing multivessel PCI is indicated because they are more likely to develop restenosis at treated sites and to experience progression of disease in untreated sites. The optimal method and time intervals for routine surveillance of these patients is uncertain. Evaluation of PCI-treated patients should be focused on the time of restenosis, that is 3 to 4 months post-intervention. For long-term follow-up of a

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