Percutaneous intervention versus coronary artery bypass graft surgery in left main coronary artery stenosis: a
Xin-Lin Zhang1, Qing-Qing Zhu2, Jing-Jing Yang3
1Department of Cardiology, Affiliated Drum Tower Hospital, Nanjing University School of Medicine, 321 Zhongshan Road, 210008, Nanjing, Jiangsu Province, China.
Insights
Percutaneous coronary intervention (PCI) with newer-generation drug-eluting stents (DES) may be a safe alternative for left main coronary artery disease (CAD). However, PCI is linked to a higher risk of repeat revascularization compared to coronary artery bypass graft (CABG).
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiovascular Surgery
Background:
- The optimal revascularization strategy for left main coronary artery disease (CAD) is a subject of ongoing debate.
- Coronary artery bypass graft (CABG) surgery has traditionally been the standard treatment for left main CAD.
- Percutaneous coronary intervention (PCI) has emerged as an alternative, necessitating a comparison of long-term outcomes.
Purpose of the Study:
- To compare the long-term effectiveness and safety of PCI versus CABG in patients with left main coronary artery disease (CAD).
- To evaluate major adverse cardiac and cerebrovascular events, mortality, and revascularization rates between the two treatment modalities.
Main Methods:
- A systematic review and meta-analysis of randomized controlled trials and matched observational studies.
- Literature search conducted in PubMed, EMBASE, and Cochrane Library up to November 16, 2016.
- Inclusion of 22,487 patients across 28 studies, with a total follow-up of 90,167 patient-years.
Main Results:
- PCI was associated with a higher risk of major adverse cardiac and cerebrovascular events, primarily driven by increased myocardial infarction and repeat revascularization rates.
- No significant differences were observed in all-cause death, cardiac death, stroke, or the composite endpoint of death, myocardial infarction, or stroke between PCI and CABG.
- Stratified analysis revealed that the increased risk of myocardial infarction with PCI was limited to bare-metal stents or early-generation drug-eluting stents (DES), not newer-generation DES.
Conclusions:
- PCI, particularly with newer-generation DES, may represent a safe alternative revascularization strategy for left main CAD.
- Despite comparable safety in terms of major adverse events and mortality, PCI is associated with a higher need for repeat revascularization compared to CABG.
- The choice of revascularization strategy should consider the specific stent generation used in PCI and patient-specific factors.
Background:
The optimal revascularization technique in patients with left main coronary artery disease (CAD) remains controversial. We aimed to compare the long-term performance of percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) surgery in treatment of left main CAD.
Methods:
PubMed, EMBASE, and the Cochrane Library were searched until November 16, 2016.
Results:
Six randomized controlled trials and 22 matched observational studies including 22,487 patients and 90,167 patient-years of follow-up were included. PCI was associated with an overall higher risk for the major adverse cardiac and cerebrovascular events (hazard ratio (HR), 1.42; 95% confidence interval (CI), 1.14-1.77), mainly driven by higher rates of myocardial infarction (HR, 1.69; 95% CI, 1.22-2.34) and revascularization (HR, 2.80; 95% CI, 1.86-4.22). The overall risks for all-cause death (HR, 1.05; 95% CI, 0.93-1.20), cardiac death (HR, 1.05; 95% CI, 0.69-1.59), stroke (HR, 0.64; 95% CI, 0.33-1.24), and the composite safety endpoint of death, myocardial infarction, or stroke (HR, 1.06; 95% CI, 0.97-1.16) were similar between PCI and CABG. Stratified analysis based on stent types showed that the increased risk for myocardial infarction associated with PCI was only evident in patients with bare-metal stents or early-generation drug-eluting stents (DES), but not newer-generation DES. Stratified analyses based on study designs showed largely similar findings with the overall analyses, except for a significantly higher incidence of myocardial infarction in adjusted studies (HR, 2.01; 95% CI, 1.64-2.45) but a trend toward higher incidence in randomized trials (HR, 1.39; 95% CI, 0.85-2.27) associated with PCI.
Conclusions:
Compared with CABG, PCI with newer-generation DES might be a safe alternative revascularization strategy for treatment of left main CAD, but is associated with more repeat revascularization.
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