PCI vs. CABG in Patients With Left Main Coronary Artery Stenosis

Study Questions:

What is the long-term safety of percutaneous coronary intervention (PCI) with drug-eluting stent (DES) versus coronary artery bypass grafting (CABG) in patients with left main coronary artery (LMCA) stenosis?

Methods:

The investigators searched PubMed, Scopus, EMBASE, Web of Knowledge, and ScienceDirect databases from December 18, 2001, to February 1, 2017. Inclusion criteria were randomized clinical trial, patients with LMCA stenosis, PCI versus CABG, exclusive use of DES, and clinical follow-up of ≥3 years. Trial-level hazard ratios (HRs) and 95% confidence intervals (CIs) were pooled by fixed-effect and random-effects models with inverse variance weighting. Time-to-event individual patient data for the primary endpoint were reconstructed. Sensitivity analyses according to DES generation and coronary artery disease (CAD) complexity were also performed. The primary endpoint was a composite of all-cause death, myocardial infarction (MI), or stroke at long-term follow-up. Secondary endpoints included repeat revascularization and a composite of all-cause death, MI, stroke, or repeat revascularization at long-term follow-up.

Results:

A total of four randomized clinical trials were pooled; 4,394 patients were included in the analysis. Of these, 3,371 (76.7%) were men; pooled mean age was 65.4 years. According to Grading of Recommendations, Assessment, Development and Evaluation, evidence quality with respect to the primary composite endpoint was high. PCI and CABG were associated with a comparable risk of all-cause death, MI, or stroke both by fixed-effect (hazard ratio [HR], 1.06; 95% confidence interval [CI], 0.90-1.24; p = 0.48) and random-effects (HR, 1.06; 95% CI, 0.85-1.32; p = 0.60) analysis. Sensitivity analyses according to low to intermediate SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) score (random-effects: HR, 1.02; 95% CI, 0.74-1.41; p = 0.89) and DES generation (first generation: HR, 0.90; 95% CI, 0.68-1.20; p = 0.49; second generation: HR, 1.19; 95% CI, 0.82-1.73; p = 0.36) were consistent. Kaplan-Meier curve reconstruction did not show significant variations over time between the techniques, with a 5-year incidence of all-cause death, MI, or stroke of 18.3% (319 events) in patients treated with PCI and 16.9% (292 events) in patients treated with CABG. However, repeat revascularization after PCI was increased (HR, 1.70; 95% CI, 1.42-2.05; p < 0.001). Other individual secondary endpoints did not differ significantly between groups. Finally, pooled estimates of trials with LMCA stenosis tended overall to differ significantly from those of trials with multivessel CAD without LMCA stenosis.

Conclusions:

The authors concluded that PCI and CABG show comparable safety in patients with LMCA stenosis and low to intermediate–complexity CAD.

Perspective:

This meta-analysis reports that, in patients with significant LMCA stenosis, both PCI with DES and CABG are associated with a comparable risk of all-cause death, MI, or stroke at long-term follow-up. However, the risk of repeat revascularization was higher for PCI at long-term follow-up compared with CABG. Overall, this analysis suggests that, in patients with significant LMCA stenosis and predominantly low to intermediate CAD complexity, both PCI and CABG may be reasonable approaches to revascularization. Patient preference should be taken into consideration regarding the risks of periprocedural complications of surgery and long-term repeat revascularization after PCI. Patients with low surgical risk may benefit from CABG owing to more sustained effectiveness, as evidenced by lower rates of repeat revascularization. On the other hand, if a patient is not a good candidate for surgery or wishes to avoid the morbidity associated with CABG, PCI appears to be a reasonable option. The findings of this study should ideally be confirmed by an adequately powered randomized trial.

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

Keywords: Cardiac Surgical Procedures, Constriction, Pathologic, Coronary Artery Bypass, Coronary Artery Disease, Coronary Stenosis, Drug-Eluting Stents, Ischemia, Myocardial Infarction, Myocardial Revascularization, Percutaneous Coronary Intervention, Stroke


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