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The
coronary artery bypass graft (CABG) surgical mortality
rate was surprisingly low in a recent trial comparing
surgery with stenting, but the principal investigator
in the Stent or Surgery (SOS) trial put the results
in context.
SOS
was one of six late-breaking interventional trials presented
on Sunday.
In
comparing rates of major clinical events associated
with stenting and surgery, the incidence of death and
nonfatal myocardial infarction in the two study groups
was essentially identical, at about 9.5 percent, said
Rodney Stables, MD, of the Royal Liverpool University
Hospital in the United Kingdom.
"A
great surprise to us was what appeared to be a mortality
advantage in patients managed with bypass grafting,"
Dr. Stables said. The mortality death rate was 1.2 percent
at two years with CABG vs. 4.1 percent with angioplasty.
Dr. Stables explained that the trial was not designed
to assess mortality and also, in absolute terms, the
number of deaths was low. He also noted that the difference
in rates appeared to hinge on an amazingly low mortality
rate for the surgery cohort and also on a higher mortality
rate from cancer in the angioplasty cohort, both of
which may have been due to chance.
In the second trial, balloon angioplasty was compared
with elective stenting for patients treated for restenosis.
The
Restenosis Intra-Stent: Balloon Angioplasty vs. Elective
Stenting (RIBS) trial, from Spain and Portugal, found
that stenting produced better outcomes in patients with
larger lumen diameter.
"We
should avoid stenting in patients with smaller vessels,"
said Fernando Alfonso, MD, of Universitario San Carlos
in Madrid. He concluded that while stenting is easy
to perform and effective in terms of minimal lumen diameter,
the restenosis rate remains high.
Surgery
produced the best one-year outcomes in the third trial
described here. The Medicine, Angioplasty, or Surgery
Study (MASS-II) trial used a three-way design to compare
outcomes of patients with multivessel coronary disease
randomized to stenting, bypass surgery, and medical
therapy.
Whady
Hueb, MD, of the University of Sao Paulo in Brazil,
said the mortality rate in the first year was similarly
low for all three treatment strategies.
Patients treated with percutaneous transluminal coronary
angioplasty (PTCA) were more likely to require further
or cross-over interventions than medical or CABG patients,
14 percent compared with 8 percent and zero, respectively.
Although
medical therapy alone was associated with a higher rate
of major combined cardiac events, the trial's primary
endpoint, it ranked between PTCA and surgical revascularization
in relation to anginal status.
"According
to the combined cardiac events during the first year,
CABG was better than PTCA and medical treatment," the
Brazilian researchers concluded.
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