CONTROVERSIES

15. Is there an advantage to surgical revascularization with all arterial conduits?

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The logical extension of the observation that an internal mammary artery has superior patency to a saphenous vein has sparked an interest in total arterial revascularization. Instead of using saphenous veins as bypass conduits, some surgeons also use the right internal mammary artery, the gastroepiploic artery, and the radial artery as bypass conduits instead of vein. Convincing data suggest a survival benefit as well as freedom from angina when the LIM artery is used as a conduit. The data supporting total arterial revascularization are much less clear.

16. What are the options for a patient with continued angina who is deemed not suitable for CABG?

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For patients on optimized medical treatment who are not surgical candidates (because of prohibitive comorbidities or poor quality coronary artery targets for bypass), an alternative is a procedure called transmyocardial myocardial revascularization (TMR). TMR uses a laser to burn small holes from the endocardium to the epicardium. Although it was originally believed that the laser brought blood from the endocardial capillary network to the myocardium, it has been repeatedly observed that laser-created channels are filled with thrombus within 24 hours and subsequently occluded. Therefore, it is postulated that the laser energy invokes an inflammatory response with a resultant increase in angiogenic factors (vascular endothelial growth factor, tumor growth factor beta, fibroblast growth factor). Although promising experimental data and clinical trials support TMR as therapeutic, one wonders if a placebo effect is not operative in promoting anginal relief.

References
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BIBLIOGRAPHY
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