Invasive Bypass Surgery for Stenosis of the Left Anterior Descending Coronary Artery. - Comparison of Stenting with Minimally Invasive Bypass Surgery for Stenosis of the Left Anterior Descending Coronary Artery

Description:

A comparison of clinical outcomes after minimally invasive bypass surgery and coronary-artery stenting for isolated stenosis of the proximal left anterior descending coronary artery.

Hypothesis:

Outcomes would be superior for minimally invasive bypass surgery compared to coronary-artery stenting for isolated stenosis of the proximal left anterior descending coronary artery.

Study Design

Study Design:

Patients Enrolled: 220
Mean Follow Up: Mean 5.6 years

Drug/Procedures Used:

The investigators randomized 220 symptomatic patients with high-grade proximal left anterior descending coronary artery stenosis to either minimally invasive surgery (110 patients) or coronary stenting (110 patients). The combined clinical end point was freedom from major adverse cardiac events, which included cardiac death, myocardial infarction, and the need for repeat target lesion revascularization within six months.

Principal Findings:

There was a significantly higher adverse cardiac event rate in patients after stenting, as compared to the surgery group (31% vs. 15%, P=0.02). The difference was primarily due to a higher rate of repeat target vessel revascularization after stenting (29% vs. 8 % P=0.003). The combined rates of death and myocardial infarction did not differ significantly between groups (3% in the stenting group and 6% in the surgery group, P=0.50). The percentage of patients free from angina after six months was 79% in the surgery group, as compared with 62% in the stenting group (P=0.03).

At 5 year follow-up, the major adverse cardiac event rate remained significantly higher in patients treated with stenting compared to bypass surgery (47% vs. 29%, relative risk 1.64, P=0.02). Target vessel revascularization also remained significantly higher in patients treated with stenting compared to bypass surgery (32% vs. 10%, relative risk 3.18, P<0.001). Improvement in angina as assessed with Canadian Cardiovascular Society (CCS) classification was greater with surgery than with stenting (CCS at 5 year follow-up 0.3 for surgery vs 0.5 for stenting, p=0.05).

Interpretation:

Among patients with a high grade left anterior descending artery stenoses, minimally invasive bypass surgery was associated with a reduction in major adverse cardiac events compared with stenting, a finding maintained through 5 years of follow-up.

Stenting was associated with good short-term results with fewer peri-procedural adverse events, but surgery was superior with regard to the need for repeat target vessel revascularization and freedom from angina at six months of follow-up and through 5 years. Major cardiac adverse event rates were significantly higher with coronary stenting compared to minimally invasive bypass surgery, driven in large part by higher target vessel revascularization rates. The availability of drug-eluting stents with very low restenosis rates may lower the difference in target vessel revascularization; however, the present trial showed a more than three-fold difference in the need for target vessel revascularization with stenting compared with bypass surgery. Future randomized studies are warranted between these strategies.

References:

Thiele H, et al. Comparison of Bare-Metal Stenting With Minimally Invasive Bypass Surgery for Stenosis of the Left Anterior Descending Coronary Artery: A 5-Year Follow-Up. Circulation. 2005;112:3445-3450.

Diegele A., Thiele H, Falk V et al. Comparison of Stenting with Minimally Invasive Bypass Surgery for Stenosis of the Left Anterior Descending Coronary Artery. N Engl J Med 2002; 347:561-66.

Clinical Topics: Invasive Cardiovascular Angiography and Intervention

Keywords: Myocardial Infarction, Coronary Stenosis, Drug-Eluting Stents, Constriction, Pathologic, Coronary Vessels, Stents, Surgical Procedures, Minimally Invasive


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