Surgery vs. Stents With Complete Revascularization

Study Questions:

What are the long-term survival rates between patients with severe coronary artery disease (CAD) undergoing coronary artery bypass grafting (CABG) and those undergoing percutaneous coronary intervention (PCI) achieving complete revascularization (CR) or incomplete revascularization?

Methods:

The investigators pooled data from the SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery), PRECOMBAT (Premier of Randomized Comparison of Bypass Surgery Versus Angioplasty Using Sirolimus-Eluting Stent in Patients With Left Main CAD), and BEST (Randomized Comparison of Coronary Artery Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients With Multivessel CAD) trials. The primary outcome was death from any cause and was compared in an as-treated analysis.

Results:

The rate of CR was 61.7% (57.2% with PCI and 66.8% with CABG). During a median 4.9-year follow-up period (interquartile range, 4.5-5.0 years), compared with patients undergoing CABG with CR, those undergoing PCI with incomplete revascularization had a higher risk for death from any cause (adjusted hazard ratio [aHR], 1.43; 95% confidence interval [CI], 1.03-2.00; p = 0.036) and the composite of death, myocardial infarction, and stroke (aHR, 1.48; 95% CI, 1.14-1.92; p = 0.003). However, there was no significant difference between patients undergoing CABG with CR and those undergoing PCI with CR regarding the risk for death from any cause (aHR, 1.16; 95% CI, 0.83-1.63; p = 0.39) and the composite of death, myocardial infarction, and stroke (aHR, 1.14; 95% CI, 0.87-1.48; p = 0.35). Subgroup analysis of multivessel coronary disease, high SYNTAX score (>32), and diabetes showed consistent findings.

Conclusions:

The authors concluded that for the treatment of left main or multivessel CAD, PCI resulting in CR was associated with a similar long-term survival rate to CABG resulting in CR.

Perspective:

This pooled analysis suggests that for the treatment of severe CAD (left main and multivessel disease), PCI resulting in CR was associated with a similar long-term survival rate to CABG resulting in CR, whereas PCI resulting in incomplete revascularization produced a lower survival rate during the ~5-year follow-up period. Furthermore, these findings were consistent in subgroups with high SYNTAX scores (>32), diabetes, and multivessel disease. It seems reasonable that the ability to achieve CR should enter into the decision algorithm for choice of revascularization strategy in severe CAD patients. Additional prospective randomized clinical trials comparing CABG versus PCI with CR in patients with multivessel CAD are needed to validate these findings. For now, a multidisciplinary team approach to individuals with severe CAD is recommended.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Prevention, Aortic Surgery, Cardiac Surgery and Arrhythmias, Interventions and Coronary Artery Disease

Keywords: Cardiac Surgical Procedures, Coronary Artery Bypass, Coronary Artery Disease, Diabetes Mellitus, Drug-Eluting Stents, Myocardial Infarction, Myocardial Revascularization, Percutaneous Coronary Intervention, Secondary Prevention, Stents, Stroke, Survival Rate


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