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Drug-eluting stents versus bilateral internal thoracic grafting for multivessel coronary disease
Itzhak Herz1, Yaron Moshkovitz, Dan Loberman
1Department of Cardiology, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
Insights
Bilateral internal thoracic artery (BITA) grafting shows better midterm outcomes than drug-eluting stent (Cypher) percutaneous coronary intervention (PCI) for multivessel revascularization, with lower rates of angina recurrence and reintervention.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
- Medical Technology
Background:
- Drug-eluting stents, such as Cypher, have shown reduced restenosis and reinterventions.
- This study directly compares multivessel Cypher stenting with bilateral internal thoracic artery (BITA) grafting.
Purpose of the Study:
- To compare the midterm clinical outcomes of multivessel myocardial revascularization using Cypher drug-eluting stents versus BITA grafting.
- To evaluate rates of restenosis, reintervention, and angina recurrence between the two revascularization methods.
Main Methods:
- A comparative study of 226 patients (113 per group) undergoing multivessel myocardial revascularization from January 2002 to June 2004.
- Patients were matched for age, sex, ejection fraction, extent of coronary disease, and congestive heart failure.
- Outcomes including mortality, angina recurrence, and reintervention rates were analyzed over a 6 to 34-month follow-up period.
Main Results:
- BITA grafting treated more coronary vessels per patient (2.87 vs 2.22).
- The Cypher group had significantly higher rates of angina recurrence (28.3% vs 12.4%) and reinterventions (14.2% vs 5.3%).
- One-year reintervention-free survival was superior for BITA grafting (96%) compared to Cypher stenting (86.6%).
Conclusions:
- Despite advancements in percutaneous coronary intervention (PCI) with drug-eluting stents, BITA grafting offers superior midterm clinical outcomes for multivessel revascularization.
- BITA grafting is associated with a lower incidence of angina recurrence and need for reintervention compared to Cypher stenting.
Background:
Reduction of restenosis and reinterventions was recently reported with percutaneous interventions (PCI), including drug-eluting stents (Cypher; Cordis, Miami Lakes, FL). This study compares results of multivessel Cypher stenting with those of bilateral internal thoracic artery (BITA) grafting.
Methods:
From January 2002 to June 2004, 768 consecutive patients underwent multivessel myocardial revascularization; 138 by PCI including Cyphers and 630 by BITA. After matching for age, sex, ejection fraction, extent of coronary disease, and congestive heart failure, two groups (113 patients each) were used to compare the two revascularization modalities.
Results:
Both groups were similar; however, left main and intraaortic balloon were more prevalent in the BITA group. The number of coronary vessels treated per patient was higher in the BITA group (2.87 vs 2.22, p < 0.001). Follow-up ranged between 6 and 34 months. Thirty-day mortality was 0.9% in the BITA and zero in the PCI group (p = 0.32). There were no late deaths in the BITA and three (2.7%) in the Cypher group (p = 0.08). Angina returned in 28.3% of the Cypher and 12.4% of the BITA group, p = 0.003. A Cox proportional hazard model revealed assignment to the Cypher group to be the only predictor of angina recurrence (odds ratio 2.78, 95% confidence interval 1.46-2.56). There were 16 (14.2%) reinterventions in the Cypher group compared with six (5.3%) in the BITA group. One-year reintervention-free survival (Kaplan-Meier) of the BITA was 96% compared with 86.6% in the Cypher group (p = 0.005, log-rank test).
Conclusions:
Despite improved results of PCI with Cyphers, midterm clinical outcome of multivessel patients treated with BITA is still better.