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Lindsay John needs to be congratulated for his rational, balanced review of revascularization techniques (January 2005 JRSM1). Twenty years ago all coronary patients were referred to the surgeons. Today most undergo angioplasty and stenting, despite recognition that surgical results are generally superior and probably not now much more costly. Furthermore, the surgical approach is more comprehensive, requires less reinvestigation and is more globally acceptable. In opposition, interventional cardiologists have accepted a constant restenosis rate, an occasional irretrievable balloon and more recently stent thrombosis reports.2 Ongoing haemorrhagic risks associated with antiplatelet agents cannot be ignored and repeated radiation exposure is hazardous to both patients and operators.
There are other considerations: what is the long term effect of metallic intrusions inside arteries? What happens when the eluting substances become depleted? As Lindsay John correctly remarks, when those stented patients eventually reach the surgeons, suitable sitings for bypass conduits can become problematic.
David Taggart in a recent article favours surgery over percutaneous interventions for severe coronary artery disease.3 I believe he is right. At best angioplasty is a time-buying operation with limited benefits. It might be more profitable for our patients if interventional cardiologists instead of becoming robotic technocrats returned to basic, unbiased clinical assessment and management and provided more supportive efforts in the aftercare of patients requiring coronary surgery. They need to candidly consider the benefits to the patients rather than apply their skills to achieve the often unachievable. The pendulum it seems has swung from one extreme to the other. It is high time to adopt a median standpoint.