In 2017 we celebrate the 40th anniversary of percutaneous coronary intervention (PCI), first performed by Andreas Gruentzig on 16 September 1977. Recognizing the limitations of percutaneous transluminal coronary balloon angioplasty (PTCA), including high rates of acute closure and restenosis, Gruentzig initially believed his technique was best reserved for patients with single-vessel coronary artery disease (CAD). Yet a number of pioneers expanded the use of PTCA to complex CAD, forecasting its superiority to coronary artery bypass graft (CABG) surgery in multivessel disease (MVD). However, early randomized trials demonstrated suboptimal outcomes of PTCA compared with CABG, especially in diabetic patients with MVD. These differences have narrowed in the last two decades, first with the introduction of bare metal stents, then with drug-eluting stents (DES). The most renowned study to probe the boundaries of PCI is the SYNTAX trial, in which 1800 patients with three-vessel or left main (LM) CAD were randomized between 2005 and 2007 to CABG vs. PCI with first-generation paclitaxel-eluting stents (PES). Surprisingly, LM patients had relatively better outcomes with PCI than those with three-vessel disease. In the latter subgroup (n = 1095), the primary endpoint of major adverse cardiac and cerebrovascular events [MACCE; death, myocardial infarction (MI), stroke, or revascularization] at 1 year occurred in 19.2% vs. 11.5% of patients after PCI vs. CABG, respectively (P < 0.001), and in 37.5% vs. 24.2%, respectively (P < 0.001), at 5 years. Thus, CABG remained the preferred revascularization modality for most patients with complex MVD. One of the greatest legacies of the SYNTAX trial is the creation of the anatomic SYNTAX score (SS). Three-vessel disease patients with low CAD complexity (SS <_ 22) in SYNTAX had similar 5-year MACCE rates with PCI and CABG, whereas those with intermediate or high CAD complexity (SS >_ 23) had superior outcomes with surgery. Notwithstanding issues in reproducibility and training, the SS has stood the test of time and has been incorporated into EU and US guidelines. The SYNTAX score II (SSII) was subsequently developed to discriminate further the outcomes of PCI vs. CABG by adding clinical variables to the anatomic SS. As elegantly described, the SSII identifies some patients with a low SS for whom CABG might be preferred, and others with a higher SS in whom PCI might be preferred, at least as regards prediction of 4-year mortality. However, after applying the SSII in the SYNTAX trial, equipoise was still present in 59% of threevessel disease patients in whom 4-year mortality could not be projected to differ between PCI and CABG with 95% certainty. In the decade since the SYNTAX trial, PCI has substantially evolved (Figure 1). The introduction of second-generation DES has markedly improved both the safety and efficacy of PCI, especially by reducing stent thrombosis, which was responsible for a substantial proportion of adverse events after PES in SYNTAX. Randomized trials have demonstrated that physiological lesion assessment can identify non-flowlimiting lesions which do not require intervention, thereby reducing stent use and MACCE. Stent optimization with intravascular ultrasound (IVUS) imaging guidance improves event-free survival, even with DES. Specialized techniques and devices to recanalize chronic total occlusions (CTOs) allow experts to achieve 90% success rates. The potent P2Y12 platelet receptor antagonists prasugrel, ticagrelor, and cangrelor reduce MI and stent thrombosis after PCI in acute coronary syndromes. Bleeding avoidance strategies, including radial artery intervention and bivalirudin, have become increasingly utilized. A large-scale network meta-analysis has suggested that PCI in the contemporary DES era may have eliminated the incremental advantage of CABG over PCI in reducing death and MI compared with medical therapy alone in stable CAD. Finally, the fundamental importance of optimal medical therapy after revascularization has also been increasingly emphasized, and may have an even greater impact on survival than choice of revascularization modality. To quantify the impact of these PCI enhancements, the SYNTAX II investigators performed PCI in 454 patients at 22 centres with three-vessel disease in whom the SSII predicted equipoise between PCI and CABG. Outcomes were compared with 315 PCI and 334

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多支血管 PCI 成立 40 周年：终于与 CABG 相匹配？

2017 年，我们庆祝经皮冠状动脉介入治疗 (PCI) 40 周年，该手术由 Andreas Gruentzig 于 1977 年 9 月 16 日首次实施。 认识到经皮冠状动脉球囊血管成形术 (PTCA) 的局限性，包括高急性闭合率和再狭窄率，Gruentzig 最初认为他的技术最适合单支血管冠状动脉疾病 (CAD) 患者。然而，许多先驱将 PTCA 的使用扩展到复杂的 CAD，预测其在多支血管疾病 (MVD) 中优于冠状动脉旁路移植术 (CABG)。然而，早期的随机试验表明，与 CABG 相比，PTCA 的结果欠佳，尤其是在 MVD 的糖尿病患者中。在过去的二十年里，这些差异已经缩小，首先是引入了裸金属支架，然后使用药物洗脱支架（DES）。探索 PCI 界限的最著名研究是 SYNTAX 试验，其中 1800 名三血管或左主干 (LM) CAD 患者在 2005 年至 2007 年间被随机分配至 CABG 组与 PCI 组，并使用第一代紫杉醇洗脱支架。 PES）。令人惊讶的是，与三支血管病变相比，LM 患者接受 PCI 的结果相对更好。在后一个亚组 (n = 1095) 中，主要不良心脑血管事件的主要终点 [MACCE; 死亡、心肌梗死 (MI)、中风或血运重建]在 PCI 和 CABG 后分别发生在 19.2% 和 11.5% 的患者中（P < 0.001），分别发生在 37.5% 和 24.2%（ P < 0.001)，在 5 年时。因此，CABG 仍然是大多数复杂 MVD 患者的首选血运重建方式。SYNTAX 试验的最大遗产之一是创建了解剖学 SYNTAX 评分 (SS)。SYNTAX 中具有低 CAD 复杂性 (SS <_ 22) 的三支血管疾病患者在 PCI 和 CABG 中的 5 年 MACCE 发生率相似，而具有中等或高度 CAD 复杂性 (SS >_ 23) 的患者在手术方面具有更好的结果。尽管在可重复性和培训方面存在问题，但 SS 经受住了时间的考验，并已被纳入欧盟和美国的指导方针。随后开发了 SYNTAX 评分 II (SSII)，通过将临床变量添加到解剖 SS 来进一步区分 PCI 与 CABG 的结果。正如优雅地描述的那样，SSII 确定了一些可能首选 CABG 的低 SS 患者，以及可能首选 PCI 的其他 SS 较高的患者，至少在预测 4 年死亡率方面是这样。然而，在 SYNTAX 试验中应用 SSII 后，59% 的三支血管疾病患者仍然存在平衡，其中不能以 95% 的确定性预测 PCI 和 CABG 之间的 4 年死亡率差异。自 SYNTAX 试验以来的十年中，PCI 发生了重大变化（图 1）。第二代 DES 的引入显着提高了 PCI 的安全性和有效性，特别是通过减少支架血栓形成，这是 SYNTAX 中 PES 后大部分不良事件的原因。随机试验表明，生理病变评估可以识别不需要干预的非限流病变，从而减少支架使用和 MACCE。血管内超声 (IVUS) 成像引导下的支架优化可提高无事件生存率，即使使用 DES。再通慢性完全闭塞 (CTO) 的专业技术和设备使专家能够达到 90% 的成功率。有效的 P2Y12 血小板受体拮抗剂普拉格雷、替格瑞洛和坎格雷洛可减少急性冠脉综合征 PCI 后 MI 和支架内血栓形成。出血避免策略，包括桡动脉介入和比伐卢定，已得到越来越多的应用。一项大规模网络荟萃分析表明，与稳定型 CAD 中的单独药物治疗相比，当代 DES 时代的 PCI 可能已经消除了 CABG 在减少死亡和 MI 方面优于 PCI 的增量优势。最后，血运重建后最佳药物治疗的根本重要性也越来越受到重视，并且可能比血运重建方式的选择对生存产生更大的影响。为了量化这些 PCI 增强的影响，SYNTAX II 研究人员对 22 个中心的 454 名三支血管病变患者进行了 PCI，其中 SSII 预测 PCI 和 CABG 之间的平衡。结果与 315 PCI 和 334