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percutaneous coronary intervention (PCI)/coronary stent vs CABG

Comparison of stent-assisted percutaneous transluminal coronary angioplasty (PTCA) versus coronary artery bypass graft (CABG). Stent or Surgery Trial (SoS) [1] Median follow-up 2 years Results: 1) combined input of death & Q-wave myocardial infarction (MI) similar in 2 groups (10%) 2) all-cause mortality lower in CABG group (2% vs 5%) 3) revascularization procedures higher in stent-PTCA group (21% vs 5%) Outcomes similar with CABG & drug-eluting stent PCI [2] CABG superior to stenting* [3] (studies did NOT include drug-eluting stents) mortality similar after 1 year (PCI, 6.6%; CABG, 6.2%) mortality at 4 years favors CABG (16.4% vs. 20.8%) [7] CABG superior to drug-eluting stents in patients with diabetes mellitus [8] - mortality & myocardial infarction lower with CABG - stroke lower with PCI & drug-eluting stent [8] CABG superior to PCI in older patients with multivessel disease [7,10] - CABG superior to PCI in patients with complex multivessel disease [16] CABG superior to PCI in patients amenable to bypass surgery with - left main coronary artery disease [27] - PCI may be appropriate for some patients with left main coronary artery disease - multivessel disease with severe systolic dysfunction or diabetes mellitus [27] - CABG is recommended for patients who have left main disease, triple vessel disease, & reduced systolic function, or multivessel disease with involvement of the proximal left anterior descending artery in the presence of diabetes [16] stenting for left main coronary artery disease with similar outcomes to CABG: - composite of death, myocardial infarction, stroke - 8.7% of patients in with stent, 6.7% with CABG [5] - after 3 years, 15.4% with stent, 14.7% with CABG [17] (neither significant) - at 30 days, 4.9% with stent, 7.9% with CABG [17] - more frequent need repeat revascularization [5] - (12.6% vs. 7.5%) [17] - CABG superior if concurrent 3-vessel disease [5] - CABG may be superior if left main disease is severe [10] - higher rates of nonprocedural MI & repeat revascularization with PCI [20] - after 5-years, all-cause mortality no different between PCI & CABG [24] - PCI or CABG reasonable for left main coronary artery disease [25] 5 year outcomes similar for composite outcomes of mortality & major cardiovascular event for left main coronary artery disease [19,26] - composite of all-cause mortality, stroke, or myocardial infarction - 19% for CABG & 22% for PCI [19] - all-cause mortality similar for PCI vs CABG for patients with acute coronary syndrome (10.9% vs 11.5%) [26] & 11.3% vs 9.6% without [26] - ischemia-driven revascularization higher for PCI vs CABG (17% vs 10%) [19] - study [19] funded by manufacturer of stent, [26] meta-analysis of 4 studies CABG with mortality benefit at 5 years vs PCI for patients with diabetes mellitus (HR=0.88) & those with a history of smoking [HR=0.82) [11] PCI with slight mortality benefit at 5 years vs CABG for patients without a history of diabetes mellitus, smoking, peripheral artery disease or heart failure [11] Patients are less likely to be compliant with their medications after CABG than after PCI [9] Advantage to CABG for total mortality (RR=0.73), incident myocardial infarction (RR=0.58), & repeat revascularization (RR=0.29) for multivessel disease [14] - patients with multivessel disease and reduced LVEF should undergo CABG rather than PCI [2] - no effect of diabetes mellitus [14] long-term mortality similar with CABG vs PCI with everolimus- eluting stent for non-diabetic patients with multivessel disease [15] - MI rates may be higher after PCI - PCI may offer early safety benefits for stroke, hemorrhage - greater risk of need for revascularization with PCI CABG superior to PCI with coronary stent in patients with multivessel disease &/or diabetes mellitus [16,18] PCI may be preferable to CABG for single-vessel disease even in patients with diabetes mellitus CABG may be preferable to PCU for ischemic cardiomyopathy with low LVEF [21] Coronary revascularization declining in US, CABG more so than stenting [6] Among older adults CABG vs PCI not different in post-procedural cognitive effects [22] major cardiovascular events 1 year after procedure was higher with fractional flow reserve-guided PCI than with CABG [23]

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artery bypass coronary coronary stent/coronary stenting percutaneous coronary intervention (PCI) tissue graft

References

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