Hybrid coronary revascularization: present and future.

C oronary revascularization provides symptomatic relief and improves long-term outcomes in patients with multi-vessel coronary artery disease (CAD).1 The ideal revascularization strategy remains controversial and depends on the anatomic complexity of the lesions that require revascularization, the comorbidities, and the ability to use dual antiplatelet therapy.1 Though coronary artery bypass grafting (CABG) is considered the gold standard of the revascularization approaches, the development of newer-generation coronary stents and safer medications have challenged this status quo. The major advantage of CABG over percutaneous coronary intervention (PCI) remains the use of the left internal mammary artery (LIMA) to bypass the left anterior descending (LAD), irrespective of its lesion complexity. The superiority of the LIMA-LAD bypass is translated into relief from angina and better long-term survival.1 On the other hand, the benefit of surgically bypassing other coronary arteries is less clear, mostly because the saphenous vein grafts (the most widely used grafts) have inferior patency rates in the long term. PCI for these lesions has been proven to be equivalent and reliable. From the patient’s perspective, PCI involves much less discomfort, a shorter hospital stay, faster recovery, and a lower risk of complications such as stroke and bleeding.2 In order to combine the advantages of the LIMA-LAD surgical bypass with the minimal invasiveness of the PCI, a hybrid approach to coronary revascularization was introduced. According to the 2011 ACCF/AHA guidelines for coronary artery bypass surgery, hybrid coronary revascularization (HCR) is defined “as the planned combination of LIMA-to-LAD artery grafting and PCI of one or more non-LAD coronary arteries”. The guidelines recommend that hybrid revascularization is reasonable (level of evidence B) in patients with one or more of the following: a. Limitations to traditional CABG, such as a heavily calcified proximal aorta or poor target vessels for CABG (but amenable to PCI). b. Lack of suitable graft conduits. c. Unfavorable LAD artery for PCI (i.e. excessive vessel tortuosity or chronic total occlusion). Finally, a level of evidence C is assigned to hybrid coronary revascularization as an alternative to multivessel PCI or CABG in an attempt to improve the overall risk-benefit ratio of the procedures.3