1. Revascularization Strategy: Syntax Score and Beyond
Ahsan Achtchi, DO, FACC

2. Disclosures & Conflict of Interest
No relevant financial relationships with any commercial interests.
No honorarium.

3. Case #1
76 M
peripheral vascular disease, type 2 diabetes mellitus, obstructive sleep apnea, morbid obesity, COPD, former smoker, HTN, HL
CCS III unstable angina

5. Revascularization? DM2 Multiple comorbidities Left main disease
Normal LVEF

6. CABG vs PCI

7. Evolution of revascularization
PCI
Improving technology
Better delivery and optimization techniques
More efficacious drugs
Staging
Need for repeat revascularization
Restenosis
CABG
Off pump techniques
Robotic, hybrid techniques
Higher likelihood of complete revascularization
Typically single procedure
Cost

8. In the past… CABG favored:
Diabetic patients with MVD, particularly LM or proximal LAD
Diminished LVEF
Composite outcomes mostly driven by repeat revascularization and ACS
BARI – CABG superior in diabetic patients, no significant difference in nondiabetics – late 1980s (POBA)
BARI-2D – high risk diabetic patients did better with CABG, lower risk favored for OMT and provisional revasc
First generation DES

12. Difference driven by need for revascularization and MI
- First generation stents and POBA (mixed bag)

13. Courage Trial

14. Limitations Excluded left main or equivalent Excluded EF less than 30%
Excluded CCS IV angina
Only ¼ of patients had > CCS II angina (75% CCS II or less)
Taxus stents
Real world adherence to intensive medical therapy

16. Syntax Trial 1800 patients 3V disease or left main 1:1 CABG or PCI
Very low enrollment of LVEF <40%
Outcomes
Death
Revascularization, MI, cerebrovascular events

17. Syntax Score Dominance Number of lesions Aorto ostial lesions
Tortuosity
Bifurcation, trifurcation disease
Heavy calcification
Length >20 mm
CTO
Thrombus
Diffuse disease

20. More recent trials BEST trial NOBLE trial, EXCEL trial
Everolimus eluting stents comparable to CABG in MVD
CABG superior at 2 years in terms of MACCE
Driven by revascularization
NOBLE trial, EXCEL trial
Syntax <32
Everolimus eluting stent noninferior to CABG

21. Case #1
76 M
peripheral vascular disease, type 2 diabetes mellitus, obstructive sleep apnea, morbid obesity, COPD, former smoker, HTN, HL
CCS III unstable angina

24. Clinical Implications
PCI is a reasonable alternative to CABG in low syntax score patients
CABG preferred in high syntax score
Intermediate score?
Other considerations
STS score
Patient preference
Other
Excludes patients with ACS and previous revascularization

25. CABG vs PCI

26. Thank you