CABG Versus PCI: Greater Benefit in Long-Term Outcomes With Multiple Arterial Bypass Grafting
Robert H Habib1, Kamellia R Dimitrova2, Sanaa A Badour3
1Department of Internal Medicine, American University of Beirut, Beirut, Lebanon; Outcomes Research Unit, American University of Beirut, Beirut, Lebanon; Vascular Medicine Program, American University of Beirut, Beirut, Lebanon.
Insights
Multiarterial coronary artery bypass grafting (MA-CABG) significantly improves long-term survival and reduces reintervention compared to percutaneous coronary intervention (PCI) with drug-eluting stents (DES) or bare-metal stents (BMS). MA-CABG is the optimal therapy for multivessel coronary artery disease.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
- Clinical Outcomes Research
Background:
- Traditional single-arterial coronary artery bypass graft (SA-CABG) shows better intermediate-term outcomes than PCI with bare-metal stents (BMS) or drug-eluting stents (DES) for multivessel coronary artery disease.
- Percutaneous coronary intervention (PCI) outcomes with BMS and DES have been previously compared to SA-CABG.
Purpose of the Study:
- To investigate the longer-term outcomes of multiarterial coronary artery bypass graft (MA-CABG).
- To compare MA-CABG with single-arterial coronary artery bypass graft (SA-CABG) and PCI (BMS and DES) in patients with multivessel coronary artery disease.
Main Methods:
- A study of 8,402 patients with multivessel coronary artery disease undergoing primary revascularization.
- Comparison of 9-year all-cause mortality and unplanned reintervention rates between BMS-PCI, DES-PCI, SA-CABG, and MA-CABG using Kaplan-Meier analysis and Cox regression.
- Exclusion of patients with recent myocardial infarction, shock, or left main stenting.
Main Results:
- BMS-PCI was associated with significantly worse survival compared to both SA-CABG and MA-CABG.
- DES-PCI showed similar survival to SA-CABG but worse survival compared to MA-CABG at 5 and 9 years.
- PCI, for both BMS and DES, resulted in substantially higher rates of reintervention compared to surgical revascularization (SA-CABG and MA-CABG).
Conclusions:
- Multiarterial surgical revascularization (MA-CABG) offers substantially enhanced death and reintervention-free survival compared to BMS-PCI and DES-PCI.
- MA-CABG is the optimal evidence-based therapy for multivessel coronary artery disease.
- Multidisciplinary heart teams should enthusiastically adopt MA-CABG for suitable patients.
Background:
Treatment of multivessel coronary artery disease with traditional single-arterial coronary artery bypass graft (SA-CABG) has been associated with superior intermediate-term survival and reintervention compared with percutaneous coronary intervention (PCI) using either bare-metal stents (BMS) or drug-eluting stents (DES).
Objectives:
This study sought to investigate longer-term outcomes including the potential added advantage of multiarterial coronary artery bypass graft (MA-CABG).
Methods:
We studied 8,402 single-institution, primary revascularization, multivessel coronary artery disease patients: 2,207 BMS-PCI (age 66.6 ± 11.9 years); 2,381 DES-PCI (age 65.9 ± 11.7 years); 2,289 SA-CABG (age 69.3 ± 9.0 years); and 1,525 MA-CABG (age 58.3 ± 8.7 years). Patients with myocardial infarction within 24 h, shock, or left main stents were excluded. Kaplan-Meier analysis and Cox regression were used to separately compare 9-year all-cause mortality and unplanned reintervention for BMS-PCI and DES-PCI to respective propensity-matched SA-CABG and MA-CABG cohorts.
Results:
BMS-PCI was associated with worse survival than SA-CABG, especially from 0 to 7 years (p = 0.015) and to a greater extent than MA-CABG was (9-year follow-up: 76.3% vs. 86.9%; p < 0.001). The surgery-to-BMS-PCI hazard ratios (HR) were as follows: versus SA-CABG, HR: 0.87; and versus MA-CABG, HR: 0.38. DES-PCI showed similar survival to SA-CABG except for a modest 0 to 3 years surgery advantage (HR: 1.06; p = 0.615). Compared with MA-CABG, DES-PCI exhibited worse survival at 5 (86.3% vs. 95.6%) and 9 (82.8% vs. 89.8%) years (HR: 0.45; p <0.001). Reintervention was substantially worse with PCI for all comparisons (all p <0.001).
Conclusions:
Multiarterial surgical revascularization, compared with either BMS-PCI or DES-PCI, resulted in substantially enhanced death and reintervention-free survival. Accordingly, MA-CABG represents the optimal therapy for multivessel coronary artery disease and should be enthusiastically adopted by multidisciplinary heart teams as the best evidence-based therapy.
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