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392 Percutaneous Coronary Intervention in The Management of Multi-Vessel CAD
in Diabetics - is There Still A Role After Freedom Trial

protocol-guided intensive medical therapy is feasible
and improves outcomes in type 2 diabetes mellitus.
In a nonrandomized analysis of survival/cardio-
vascular events and control of 6 RFs (no smoking,
non-high-density lipoprotein cholesterol <130 mg/
dl, triglycerides <150 mg/dl, blood pressure [systol-
ic <130 mm Hg; diastolic <80 mm Hg], glycosylated
hemoglobin <7%) in BARI 2D(6) trial, there was a 2
fold decrease in death rate in patients with all 6 risk
factors in the optimal range compared to patients
with 0 to 2 RFs in control.

Figure 2: CT angiography showing Left internal mam-
mary artery graft to the distal LAD and a Saphenous
venous graft to the distal RCA. The Proximal RCA
and LAD are diffusely diseased with heavy plaque
burden.

Figure 1: Reduction in MACE with control of risk fac-
tors.
How CABG differs from PCI
Bypass grafts from the Aorta and the mammary
arteries are anastomosed to distal, usually healthy
portion of coronary arteries. Vulnerable plaque is
common in the proximal portions of coronary ar-
teries and this increases the lifetime risk of future Figure 3 : CT angiography showing proximal LAD
myocardial infarctions. The underlying rationale is stent with extensive ulcerated complex plaque distal
that the bypass graft will confer longer-term protec- to the stent
tion (for the lifespan of the graft) by preventing the
clinical consequences of plaque rupture/myocardial Contemporary surgical practices – Off-pump CABG
infarction, compared with a stent which would treat have not shown to be superior to on-pump CABG in
the obstructive lesion alone. Atherosclerotic process terms of clinical outcomes. Recent trials- ROOBY(7),
is diffuse and disease typically progresses distal to CORONARY(8) and GOPCABE(9).
the stented segment. Hence patients who undergo All three trials showed similar prevalence of death,
PCI are not “protected” by plaque rupture that occurs stroke, and acute renal failure at 30 days among pa-
distal to the stents.
tients who underwent off-pump CABG and those who
underwent on-pump CABG. However trials showed
that patients who underwent off-pump CABG had
fewer bypass grafts than those who underwent on-
pump CABG, a finding that suggests more incom-
plete revascularization. In addition, both the CORO-
NARY and GOPCABE trials showed a higher preva-
lence of repeat revascularization at 30 days among
patients who underwent off-pump CABG than among
those who underwent on-pump CABG, a finding that
suggests less effective revascularization.
In the 5 yr follow up of the ROOBY trial the rate of
death at 5 years was 15.2% in the off-pump group

GCDC 2017