PCI Vs CABG for MultivesselPCI Vs CABG for Multivesseland Unprotected LM Diseaseand Unprotected LM Disease
SCRIPPS CLINIC
Paul S. Teirstein
Chief of Cardiology
Director, Interventional Cardiology
Scripps Clinic
Disclosure Statement of Financial InterestDisclosure Statement of Financial Interest
Within the past 12 months, I or my spouse/partner have had a financialinterest/arrangement or affiliation with the organization(s) listed below.
Affiliation/Financial Relationship Company
Grant/Research Support Boston, Abbott, Medtronic, Edwards
Consulting Fees/Honoraria Boston, Abbott, Medtronic, Edwards
President (unpaid) NBPAS
SCRIPPS CLINIC
PCI and CABG for Treating Stable Coronary Artery DiseaseJACC Review Topic of the WeekTorsten Doenst, Axel Haverich, Patrick Serruys, Robert O. Bonow, Pieter Kappetein,Volkmar Falk, Eric Velazquez, Anno Diegeler and Holger Sigusch
Torsten Doenst et al. JACC 2019;73:964-976
2019 American College of Cardiology Foundation
SYNTAX 4-year Outcomes in the 3VD Subgroup • TCT 2011 • November, 2011 • Mohr • Slide 5
Survival = 70.6% PCI Vs 74.4% CABG NNT 26
SYNTAX 4-year Outcomes in the 3VD Subgroup • TCT 2011 • November, 2011 • Mohr • Slide 6
Survival = 70.8% PCI Vs 78.1% CABG NNT 14
SYNTAX 4-year Outcomes in the 3VD Subgroup • TCT 2011 • November, 2011 • Mohr • Slide 7
CABG PCI P value
Death 8.8% 17.8% 0.02
CVA 2.6% 5.1% 0.31
MACCE to 5 Years by SYNTAX Score TercileMACCE to 5 Years by SYNTAX Score Tercile3VD Subset3VD Subset High Scores ≥33High Scores ≥33
TAXUS (N=155)
CABG (N=166)
P<0.00141.9%
3-Vessel Disease
Cum
ula
tive
Event
Rate
(%)
50
SYNTAX 4-year Outcomes in the 3VD Subgroup • TCT 2011 • November, 2011 • Mohr • Slide 8
Site-reported Data; ITT populationCumulative KM Event Rate ± 1.5 SE; log-rank P value
MI 1.9% 8.7% 0.008
Death,CVA or
MI12.5% 26.2% 0.002
Revasc. 12.6% 28.2% <0.001
24.1%
Months Since Allocation
Cum
ula
tive
Event
Rate
(%)
0 12 24
0
25
4836 60
CABG PCI P value
Death 9.6% 16.3% 0.047
CVA 3.6% 2.5% 0.53
MACCE to 5 Years by SYNTAX ScoreMACCE to 5 Years by SYNTAX Score TercileTercile3VD Subset3VD Subset Intermediate Scores 23Intermediate Scores 23--3232
TAXUS (N=207)
CABG (N=208)
37.9%
3-Vessel Disease
Cum
ula
tive
Event
Rate
(%)
50
P<0.001
SYNTAX 4-year Outcomes in the 3VD Subgroup • TCT 2011 • November, 2011 • Mohr • Slide 9
MI 3.1% 13.8% <0.001
Death,CVA or
MI14.7% 23.2% 0.04
Revasc. 11.0% 25.1% <0.001
Site-reported Data; ITT populationCumulative KM Event Rate ± 1.5 SE; log-rank P value
22.6%
Months Since Allocation
Cum
ula
tive
Event
Rate
(%)
0 12 24
0
25
4836 60
CABG PCI P value
Death 9.3% 10.2% 0.81
CVA 3.9% 1.8% 0.24
MACCE to 5 Years by SYNTAX ScoreMACCE to 5 Years by SYNTAX Score TercileTercile3VD Subset3VD Subset Low Scores 0Low Scores 0--2222
3-Vessel Disease
TAXUS (N=181)
CABG (N=171)
Cum
ula
tive
Event
Rate
(%)
50
P=0.21
SYNTAX 4-year Outcomes in the 3VD Subgroup • TCT 2011 • November, 2011 • Mohr • Slide 10
MI 4.9% 8.8% 0.20
Death,CVA or
MI14.8% 17.5% 0.56
Revasc. 14.6% 23.1% 0.04
Site-reported Data; ITT populationCumulative KM Event Rate ± 1.5 SE; log-rank P value
33.3%
26.8%
Months Since Allocation
Cum
ula
tive
Event
Rate
(%)
0 12 24
0
25
4836 60
CABG Vs PCI: A Different PerspectiveCABG Vs PCI: A Different Perspective
• The BEST trial: In patients with mean SYNTAX score of 25, outcomedifferences were confined to the Repeat Revascularization endpoint:
PCI CABGAny Revascularization: 11% 5.4% (51% relative reduction)
SCRIPPS CLINIC
Any Revascularization: 11% 5.4% (51% relative reduction)
Freedom from Revasc: 89% 94.6% (6.2% absolute increase)
NNT to prevent one revascularization =18
Are we really going to bypass 18 patients to prevent one repeat PCI?
PCI Vs CABG for UnprotectedPCI Vs CABG for UnprotectedLeft MainLeft Main
SCRIPPS CLINIC
Left MainLeft Main
The Synergy between PercutaneousThe Synergy between PercutaneousCoronary Intervention with TAXUS andCoronary Intervention with TAXUS and
Cardiac Surgery: The SYNTAX StudyCardiac Surgery: The SYNTAX Study
The 5The 5--year Outcomes of the SYNTAXyear Outcomes of the SYNTAXTrial in the Subset of Patients WithTrial in the Subset of Patients With
ThreeThree--vessel Diseasevessel Disease
The Synergy between PercutaneousThe Synergy between PercutaneousCoronary Intervention with TAXUS andCoronary Intervention with TAXUS and
Cardiac Surgery: The SYNTAX StudyCardiac Surgery: The SYNTAX Study
The 5The 5--year Outcomes of the SYNTAXyear Outcomes of the SYNTAXTrial in the Subset of Patients WithTrial in the Subset of Patients With
ThreeThree--vessel Diseasevessel Disease
SYNTAX 4-year Outcomes in the 3VD Subgroup • TCT 2011 • November, 2011 • Mohr • Slide 18
ThreeThree--vessel Diseasevessel DiseaseThreeThree--vessel Diseasevessel Disease
Friedrich W. Mohr, MD PhDFriedrich W. Mohr, MD PhDUniversity of Leipzig Heart CenterUniversity of Leipzig Heart CenterOn behalf of the SYNTAX investigatorsOn behalf of the SYNTAX investigators
Tuesday, November 8th 11:33Tuesday, November 8th 11:33Oral Abstract Sessions: DrugOral Abstract Sessions: Drug--eluting Stents I andeluting Stents I and
BioabsorbableBioabsorbable ScaffoldsScaffoldsConflicts of Interest: NoneConflicts of Interest: None
P=0.12
Cum
ula
tive
Event
Rate
(%)
50
Before 1 year*
13.7% vs 15.8%
P=0.44
1-2 years*
7.5% vs 10.3%P=0.22
2-3 years*
5.2% vs 5.7%P=0.78
3-4 years*
6.4% vs 8.3%P=0.35
36.9%
TAXUS (N=357)CABG (N=348)
MACCE to 5 YearsLeft Main SubsetLeft Main Subset
4-5 years*
5.9% vs 5.5%P=0.82
SYNTAX 4-year Outcomes in the LM Subgroup • TCT 2011 • November 2011 • Serruys • Slide 19
31.0%
0
Cum
ula
tive
Event
Rate
(%)
25
Months Since Allocation0 12 6024 36 48
Serruys PW. TCT2012
SYNTAXES 10 year data
SYNTAX 4-year Outcomes in the 3VD Subgroup • TCT 2011 • November, 2011 • Mohr • Slide 20
TAXUS (N=135)
CABG (N=149)CABG PCI P value
Death 14.1% 20.9% 0.11
CVA 4.9% 1.6% 0.13
LM Disease
Cum
ula
tive
Event
Rate
(%)
50
MACCE to 5 Years by SYNTAX Score TercileMACCE to 5 Years by SYNTAX Score TercileLM SubsetLM Subset High Scores ≥33High Scores ≥33
46.5%P=0.003
SYNTAX 4-year Outcomes in the LM Subgroup • TCT 2011 • November 2011 • Serruys • Slide 21
MI 6.1% 11.7% 0.13
Death,CVA or
MI22.1% 26.1% 0.40
Revasc. 11.6% 34.1% <0.001Months Since Allocation
Cum
ula
tive
Event
Rate
(%)
0 12 24
0
25
4836 60
29.7%
Serruys PW. TCT2012
CABG PCI P value
Death 19.3% 8.9% 0.04
CVA 3.6% 1.0% 0.23
TAXUS (N=103)
CABG (N=92)
32.7%
LM Disease
Cum
ula
tive
Event
Rate
(%)
50
MACCE to 5 Years by SYNTAX ScoreMACCE to 5 Years by SYNTAX Score TercileTercileLM SubsetLM Subset Intermediate Scores 23Intermediate Scores 23--3232
P=0.88
SYNTAX 4-year Outcomes in the LM Subgroup • TCT 2011 • November 2011 • Serruys • Slide 22
MI 4.6% 6.0% 0.71
Death,CVA or
MI24.9% 15.7% 0.11
Revasc. 16.6% 22.2% 0.40
32.7%
32.3%
Months Since Allocation
Cum
ula
tive
Event
Rate
(%)
0 12 24
0
25
4836 60
Serruys PW. TCT2012
CABG PCI P value
Death 11.3% 7.0% 0.28
CVA 4.1% 1.8% 0.28
LM Disease
TAXUS (N=118)
CABG (N=104)
MACCE to 5 Years by SYNTAX ScoreMACCE to 5 Years by SYNTAX Score TercileTercileLM SubsetLM Subset Low Scores 0Low Scores 0--2222
Cum
ula
tive
Event
Rate
(%)
50
P=0.74
SYNTAX 4-year Outcomes in the LM Subgroup • TCT 2011 • November 2011 • Serruys • Slide 23
MI 3.1% 6.2% 0.32
Death,CVA or
MI15.2% 13.9% 0.71
Revasc. 20.3% 23.0% 0.65
30.4%
31.5%
Months Since Allocation
Cum
ula
tive
Event
Rate
(%)
0 12 24
0
25
4836 60
Serruys PW. TCT2012
EXCELFive-year Outcomes from a Randomized
Trial of PCI vs. CABG in Patients withLeft Main Coronary Artery Disease
Gregg W. Stone MDfor A. Pieter Kappetein, Joseph F. Sabik,
Patrick W. Serruys and the EXCEL investigators
Left Main Coronary Artery Disease
Randomization and Follow-up
1905 ptswith unprotected
left main CADwere enrolled
PCI withCoCr-EES
N=948
Initial treatment
PCI (n=935)
CABG (n=7)
No revascularization (n=6)
942 (99.4%) 918 (96.8%) 884 (93.2%)
Withdrew; n=6Lost to follow-up; n=0
Withdrew; n=5Lost to follow-up; n=19
Withdrew; n=0Lost to follow-up; n=34
were enrolledbetween
9/29/2010 and3/6/2014 at126 sites in17 countries
CABGN=957
R
Initial treatment
PCI (n=17)
CABG (n=923)
No revascularization (n=17)
30-dayfollow-up
5-yearfollow-up
3-yearfollow-up
940 (98.2%) 899 (93.9%) 862 (90.1%)
Withdrew; n=16Lost to follow-up; n=1
Withdrew; n=17Lost to follow-up; n=24
Withdrew; n=1Lost to follow-up; n=36
Study Design
2900 pts with unprotected left main disease2900 pts with unprotected left main disease
SYNTAX score ≤32SYNTAX score ≤32Consensus agreement of eligibility and equipoise by heart teamConsensus agreement of eligibility and equipoise by heart team
YesYes
NoNo(N=1000)(N=1000)
R
FollowFollow--up: 1 month, 6 months, 1 year, annually through 5 yearsup: 1 month, 6 months, 1 year, annually through 5 yearsPrimary endpoint:Primary endpoint: Measured at a median 3Measured at a median 3--yr FU, minimum 2yr FU, minimum 2--yr FUyr FU
YesYes
(N=1900)(N=1900)EnrollmentEnrollment
registryregistry
PCI (PCI (XienceXience EES)EES)(N=950)(N=950)
CABGCABG(N=950)(N=950)
Stratified by diabetes,Stratified by diabetes, SYNTAX score andSYNTAX score andcentercenter
FU = 93.3% FU = 91.0%
SYNTAX Score
Site Reported Core LabLow (≤22)
Intermediate (23-32)
High (≥33)
PCI59.2%40.8%
42.8%
25.1%
32.2%
CABG61.8%38.2%
Mean 20.6 ± 6.2
Mean 20.5 ± 6.1
P=0.5237.3%
23.4%
39.3%
Mean 26.9 ± 8.8
Mean 26.0 ± 9.8
P=0.005
Core Lab DataPCI (N=942) CABG (N=936)
Qualifying LM lesion*
- LM coronary segment 97.6% 97.0%
- LM equivalent disease** 1.2% 1.5%
- Neither 1.3% 1.5%
Distal LM bifurcation or trifurcation ds. 81.8% 79.2%Distal LM bifurcation or trifurcation ds. 81.8% 79.2%
# Diseased non-LM coronary arteries*
- 0 17.3% 17.8%
- 1 31.0% 31.2%
- 2 34.5% 31.5%
- 3 17.2% 19.4%
*DS ≥50% by QCA**DS of both the ostial left LAD and ostial LCX ≥50% by QCA
15
20
25
CABG (n=957)
PCI (n=948)
str
ok
eo
rM
I(%
)
Primary EndpointAll-cause Death, Stroke or MI at Median 3 Years
15.4%14.7%
0
5
10
De
ath
,s
tro
ke
0 12 24 36 48 60
MonthsPCI 948
Number at risk:
850 784 445
CABG 957 817 763 458
Stone GW et al. N Engl J Med 2016;375:2223-35
HR [95%CI] =1.00 [0.79, 1.26]
P = 0.98
15
20
25
22.0%
19.2%
str
ok
eo
rM
I(%
)
Primary EndpointAll-cause Death, Stroke or MI at 5 Years
CABG (n=957)
PCI (n=948)
OR [95% CI] =1.19 [0.95, 1.50]
P=0.13
0
5
10
De
ath
,s
tro
ke
0 12 24 36 48 60
MonthsPCI 948
Number at risk:
854 809 778 738 486
CABG 957 818 789 763 734 532
Piecewise Hazards
All-cause Death, Stroke or MIThree distinct periods of varying relative risk
15
20
or
MI
(%)
15.1%
0-day to 30-day HR: 0.61 [95% CI: 0.42, 0.88]; P-value = 0.008
30-day to 1-year HR: 1.07 [95% CI: 0.68, 1.70]; P-value = 0.76
1-year to 5-year HR: 1.61 [95% CI: 1.23, 2.12]; P-value <0.001
Treatment-time interaction: P<0.001CABG (n=957)
PCI (n=948)
0
5
10
De
ath
,s
tro
ke
or
MI
(%)
0 12 24 36 48 60
Months
8.0%
3.8%
9.7%
4.9% 4.1%
Number at risk:
PCIPCI
CABGCABG 957
948
889 856 827 794 579
902 854 819 776 511
1-year to 5-year HR: 1.61 [95% CI: 1.23, 2.12]; P-value <0.001
929
933
1
15
20
25
22.0%
19.2%
str
ok
eo
rM
I(%
)
Primary EndpointAll-cause Death, Stroke or MI at 5 Years
CABG (n=957)
PCI (n=948)
78% vs 80.8% Freedom From Death, Stroke or MIABS diff = 2.8 NNT = 37
Need to do 37 CABG to prevent 1 Death, Stroke or MI
OR [95% CI] =1.19 [0.95, 1.50]
P=0.13
0
5
10
De
ath
,s
tro
ke
0 12 24 36 48 60
MonthsPCI 948
Number at risk:
854 809 778 738 486
CABG 957 818 789 763 734 532
Primary Endpoint at 5 YearsPCI (N=948) CABG (N=957) Difference [95% CI] Odds ratio [95% CI]
Death, stroke or MI 22.0% (203) 19.2% (176) 2.8% [-0.9%, 6.5%] 1.19 [0.95, 1.50]
Death, all-cause 13.0% (119) 9.9% (89) 3.1% [0.2%, 6.1%] 1.38 [1.03, 1.85]
- Cardiovascular 6.8% (61) 5.5% (49) 1.3% [-0.9%, 3.6%] 1.26 [0.85, 1.85]
- Definite cardiovascular 5.0% (45) 4.5% (40) 0.5% [-1.4%, 2.5%] 1.13 [0.73, 1.74]
- Undetermined cause 1.9% (16) 1.1% (9) 0.9% [-0.3%, 2.0%] 1.78 [0.78, 4.06]- Undetermined cause 1.9% (16) 1.1% (9) 0.9% [-0.3%, 2.0%] 1.78 [0.78, 4.06]
- Non-cardiovascular 6.6% (58) 4.6% (40) 2.0% [-0.2%, 4.2%] 1.47 [0.97, 2.23]
Cerebrovascular events 3.3% (29) 5.2% (46) -1.9% [-3.8%, 0.0%] 0.61 [0.38, 0.99]
- Stroke 2.9% (26) 3.7% (33) -0.8% [-2.4%, 0.9%] 0.78 [0.46, 1.31]
- Transient ischemic attack 0.3% (3) 1.6% (14) -1.3% [-2.2%, -0.4%] 0.21 [0.06, 0.74]
Myocardial infarction 10.6% (95) 9.1% (84) 11.4% [-1.3%, 4.2%] 1.14 [0.84, 1.55]
- Peri-procedural 3.9% (37) 6.1% (57) -2.1% [-4.1%, -0.1%] 0.63 [0.41, 0.96]
- Non-peri-procedural 6.8% (59) 3.5% (31) 3.2% [1.2%, 5.3%] 1.96 [1.25, 3.06]
All-cause Death, Stroke or MI
15
20
or
MI
(%)
15.1%
0-day to 30-day HR: 0.61 [95% CI: 0.42, 0.88]; P-value = 0.008
30-day to 1-year HR: 1.07 [95% CI: 0.68, 1.70]; P-value = 0.76
1-year to 5-year HR: 1.61 [95% CI: 1.23, 2.12]; P-value <0.001
Treatment-time interaction: P<0.001CABG (n=957)
PCI (n=948)
Even if one extrapolates (by doubling theevent rates from 1-5 years), by year 10 allcause death, stroke or MI is 38.9% Vs31.5% favoring CABG. The NNT is 13.5.
Freedom from death, stroke of MI is 61.1%with PCI Vs 68.5% with CABG
0
5
10
De
ath
,s
tro
ke
or
MI
(%)
0 12 24 36 48 60
Months
8.0%
3.8%
9.7%
4.9% 4.1%
Number at risk:
PCIPCI
CABGCABG 957
948
889 856 827 794 579
902 854 819 776 511
1-year to 5-year HR: 1.61 [95% CI: 1.23, 2.12]; P-value <0.001
929
933
1
Additional Outcomes at 5 Years
PCI (N=948) CABG (N=957) Difference [95% CI] Odds ratio [95% CI]
Death, stroke, MI or IDR 31.3% (290) 24.9% (228) 6.5% [2.4%, 10.6%] 1.39 [1.13, 1.71]
- ID-revascularization 16.9% (150) 10.0% (88) 6.9% [3.7%, 10.0%] 1.84 [1.39, 2.44]
- PCI 14.1% (125) 9.1% (80) 4.9% [1.9%, 7.9%] 1.65 [1.22, 2.22]
- CABG 4.3% (38) 0.9% (8) 3.4% [1.9%, 4.9%] 4.90 [2.27, 10.56]
All revascularization 17.2% (153) 10.5% (92) 6.7% [3.5%, 9.9%] 1.79 [1.36, 2.36]
Stent thrombosis 1.8% (16) 0% (0) - -
- Definite 1.1% (10) 0% (0) - -
- Probable 0.7% (6) 0% (0) - -
Symptomatic graft occlusion 0% (0) 6.5% (58) - -
Therapy failure* 1.1% (10) 6.5% (58) -5.4% [-7.2%, -3.6%] 0.16 [0.08, 0.32]
*Definite stent thrombosis or symptomatic graft occlusion. ID = ischemia-driven.
Conclusions
• In the EXCEL trial, treatment of patients with LMCAD
and visually-assessed low or intermediate SYNTAX
scores with CoCr-EES resulted in similar rates of the
clinically meaningful composite outcome of death, stroke
or MI at 5 yearsor MI at 5 years
• The early benefits of PCI due to reduced peri-procedural
risk were attenuated by the greater number of events
occurring during follow-up with CABG, such that at
5 years the cumulative mean time free from adverse
events was similar with both treatments
Conclusions
• PCI may thus be considered an
acceptable revascularization modality
for selected patients with LMCAD, a
decision which should be made afterdecision which should be made after
heart team discussion, taking into
account each patient’s individual risk
factors and preferences
Subgroup analyses
Distal LMBifurcationsonly
NNT = 17It takes 17open chestsurgeriesto prevent1 repeatPCIPCI
Giustino G, et al; J Am Coll Cardiol. 2018 Aug 14;72(7):754-765
Acute renal failure at 30 days in patients with or without CKDAcute renal failure at 30 days in patients with or without CKDundergoing PCI versus CABGundergoing PCI versus CABG
Chronic Kidney Disease (n = 361) No Chronic Kidney Disease (n = 1508)
pinteractionPCI
(n = 177)
CABG
(n = 184)
Hazard Ratio
(95% CI)
PCI
(n = 757)
CABG
(n = 751)
Hazard Ratio
(95% CI)
Acute renal failure† 4/177 (2.3%) 14/184 (7.6%) 0.28 (0.09-0.87) 2/757 (0.3%) 10/751 (1.3%) 0.20 (0.04-0.90) 0.71
New requirement for
dialysis
2/177 (1.1%) 10/184 (5.4%) 0.20 (0.04-0.92) 1/757 (0.1%) 4/751 (0.5%) 0.25 (0.03-2.22) 0.87
dialysis
Hemodialysis 1/177 (0.6%) 5/184 (2.7%) 0.20 (0.02-1.76) 1/757 (0.1%)* 3/751 (0.4%) 0.33 (0.03-3.18) 0.76
CVVH 1/177 (0.6%) 5/184 (2.7%) 0.20 (0.02-1.76) 1/757 (0.1%)* 1/751 (0.1%) 0.99 (0.06-15.89) 0.38
†Defined as the rise in serum creatinine >5 mg/dL or a new requirement for dialysis. *One patient in the no chronic kidney disease group had bothCVVH and hemodialysis. CVVH: Continuous veno-venous hemofiltration.
Giustino G, et al; J Am Coll Cardiol. 2018 Aug 14;72(7):754-765
Unprotected LM Stenting- Caveats
• EXCEL mostly provisional…results would likely be better with DK crush• Most UPLM bifurcations can be done radially• 6FR can be cumbersome but is certainly doable and may cause slightly less radial
artery occlusion. If you are more comfortable with 7Fr, use Slender sheath radial• Beware of longitudinal compression when treating LM lesions.• Impella can provide very helpful support for these patients. Please think about Impella
before referring UPLM patients for CABG
SCRIPPS CLINIC
before referring UPLM patients for CABG• IVUS should be set up at the start of the case…and used• Data indicates DK crush is preferred, but Coulotte and TAP are also okay…make sure
you are comfortable with the technique you use.• If left main SB FFR >.8 then provisional stenting of SB is not immoral but…• 2 stent data is better, and if you like pretty pictures, you will be happier with 2 stents
for UPLM bifurcations.
When do I send a 3VD +/orUPLM patient for CABG ?
High SYNTAX score with 3VD and/or LM disease
Intermediate SYNTAX score with 3VD
In borderline SYNTAX score patients, IDDM sways metowards CABG
DAPT intolerant patient
Total occlusions with large and important territory at risk,
SCRIPPS CLINICSCRIPPS CLINIC
Total occlusions with large and important territory at risk,not amenable to PCI or failed PCI
Several restenoses, large territory at risk
Poor PCI candidate, ie excessive proximal tortuosity,particularly if calcified with good distal targets
When do I break the above rules:
- Poor CABG candidate, ie frailty, O2 dependent, no targets
- Patient preference? Especially when SYNTAX borderline
The Heart Team and“Shared Decision Making” are overrated.
• Medicine is not a democracy
The heart team and borderline cases
• Few patients can really analyze the data and make an informeddecision
SCRIPPS CLINIC
Patients make decisions based mostly on
the confidence they get from the surgeon or interventionalist
Their fear of major surgery
The experiences of their friends and family
You Can Call Me Now…
• Bypass surgery is very hard to go through more than once
Your saphenous vein grafts will likely close down
Your native vessels will likely shrivel up
Your subsequent PCI will likely be more difficult
…Or You Can Call Me Later
But Remember:
SCRIPPS CLINIC
Your subsequent PCI will likely be more difficult
• But, PCI can be repeated as often as you like
And you can always have a bypass
Sometime in the future
Or, maybe never
Bypass the Bypass!
SCRIPPS CLINIC
Bypass the Bypass!
SCRIPPS CLINIC