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Left Internal Mammary Artery Versus Coronary Stents: Impact on Downstream Coronary Stenoses and Conduit Patency
Ming Zhang1, Raviteja R Guddeti2, Yasushi Matsuzawa2
1Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
Insights
Left internal mammary artery (LIMA) grafting significantly reduces downstream coronary and conduit disease progression compared to percutaneous coronary intervention with bare metal stents (BMS) or drug-eluting stents (DES). This finding offers valuable insights for long-term treatment strategies in coronary artery disease.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
- Vascular Biology
Background:
- Coronary artery disease management involves choosing between surgical bypass and stenting.
- Long-term outcomes regarding disease progression in bypass grafts versus stents are critical for patient care.
- The left anterior descending artery is a common target for revascularization, making its treatment outcomes highly significant.
Purpose of the Study:
- To compare the progression of downstream coronary and conduit disease after revascularization of the left anterior descending artery.
- To evaluate the efficacy of left internal mammary artery (LIMA) bypass grafting against percutaneous coronary intervention (PCI) using bare metal stents (BMS) and drug-eluting stents (DES).
Main Methods:
- A retrospective analysis of 2386 patients undergoing isolated primary coronary revascularization.
- Propensity score matching identified 628 patients for comparative analysis: LIMA (n=314), BMS (n=94), and DES (n=60).
- Quantitative coronary angiography (QCA) assessed disease progression, analyzed using Kaplan-Meier and Cox proportional hazard models.
Main Results:
- LIMA grafting showed significantly lower downstream coronary disease progression compared to BMS (HR 0.34) and DES (HR 0.39).
- LIMA also demonstrated a significantly lower risk of conduit disease progression versus BMS (HR 0.18) and DES (HR 0.27).
- While BMS showed a trend towards higher progression than DES, it did not reach statistical significance.
Conclusions:
- Left internal mammary artery (LIMA) grafting to the left anterior descending artery is superior in preventing downstream coronary and conduit disease progression.
- LIMA grafting offers a more durable solution compared to percutaneous coronary intervention with BMS and DES for the left anterior descending artery.
Background:
The study compared downstream coronary and conduit disease progression in the left anterior descending coronary artery treated with coronary artery bypass grafting using the left internal mammary artery (LIMA) versus percutaneous coronary intervention with bare metal stent (BMS) or drug eluting stent (DES).
Methods And Results:
A total of 12 301 consecutive patients underwent isolated primary coronary revascularization, of which 2386 met our inclusion criteria (Percutaneous coronary intervention, n=1450; coronary artery bypass grafting, n=936). Propensity score analysis matched 628 patients, of which 468 were treated to the left anterior descending with coronary artery bypass grafting with LIMA (n=314), percutaneous coronary intervention with BMS (n=94), and DES (n=60). Coronary angiograms were analyzed by quantitative coronary angiography (QCA; n=433). Cumulative downstream coronary and conduit disease progression were estimated by Kaplan-Meier method and effect of treatment type by Cox proportional hazard models. Patients treated with LIMA had significantly lower risk of downstream coronary disease progression at follow-up angiogram compared with BMS and DES (hazard ratio [HR] [95% CI], 0.34; [0.20-0.59]; P=0.0002; and HR [95% CI], 0.39; [0.20-0.79]; P=0.01, respectively). LIMA was associated with a lower risk of conduit disease progression compared to BMS and DES (HR [95% CI], 0.18; [0.12-0.28]; P<0.001; and HR [95% CI], 0.27; [0.16-0.46]; P<0.001, respectively). BMS was associated with higher HR for downstream coronary and conduit disease progression compared with DES, but the difference did not reach statistical significance (HR [95% CI], 1.13; [0.57-2.36]; P=0.73; and HR [95% CI], 1.46; [0.88-2.50]; P=0.14, respectively).
Conclusions:
LIMA grafting to left anterior descending is associated with significantly lower risk of downstream coronary and conduit disease progression compared to percutaneous coronary intervention with BMS and DES.
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