When and why should we employ the surgeon? Biological and clinical rationale for early reperfusion

Revascularization in patients with coronary artery disease (CAD) has changed over the last two decades, favoring the use of percutaneous coronary intervention (PCI) over coronary artery bypass grafting (CABG), even though there is no available hard evidence to support this change. Nevertheless, PCI stenting has been progressively expanding its indications to include multivessel coronary disease, diabetes mellitus, and left main stem coronary artery disease. Proponents of PCI justify its expansion with the improvement in restenosis achieved with drug-eluting stents. However, the established treatment of CAD is CABG, with proven long-term life expectancy benefit. The ongoing replacement of CABG with PCI would be therefore justified only if a critical scrutiny of the evidence clearly demonstrates similar or better life expectancy benefits.