Single or multiple arterial bypass graft surgery vs. percutaneous coronary intervention in patients with three-vessel
Piroze M Davierwala1, Chao Gao2,3,4, Daniel J F M Thuijs5
1Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, 200 Elizabeth St, Toronto, ON M5G 2C4, Canada.
Insights
Multiple arterial grafting (MAG) in coronary artery bypass grafting (CABG) significantly reduces long-term mortality compared to percutaneous coronary intervention (PCI). MAG offers better survival outcomes for patients with three-vessel disease and/or left main coronary artery disease.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
- Clinical Outcomes Research
Background:
- Coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are primary revascularization strategies.
- The choice between single arterial grafting (SAG) and multiple arterial grafting (MAG) in CABG impacts long-term outcomes.
- Long-term survival data comparing PCI with different arterial grafting strategies in complex coronary artery disease are limited.
Purpose of the Study:
- To compare long-term all-cause mortality between PCI and CABG using MAG or SAG.
- To evaluate the efficacy of different revascularization strategies in patients with three-vessel disease (3VD) and/or left main coronary artery disease (LMCAD).
Main Methods:
- Post hoc analysis of the SYNTAX Extended Survival Study (SYNTAXES).
- Included 1743 patients with 3VD and/or LMCAD, followed for a median of 11.9 years.
- Compared all-cause mortality in patients treated with PCI, SAG-CABG, and MAG-CABG.
Main Results:
- MAG-CABG was associated with significantly lower all-cause mortality compared to PCI (adjusted HR 0.66).
- SAG-CABG showed a trend towards lower mortality than PCI but did not reach statistical significance (adjusted HR 0.83).
- In 3VD patients, both MAG and SAG were superior to PCI; no significant differences were found in LMCAD patients.
Conclusions:
- Multiple arterial grafting (MAG) may be a superior CABG strategy to PCI for reducing long-term mortality in patients with 3VD and/or LMCAD.
- The number of myocardial territories revascularized with arterial grafts positively correlates with survival.
- Further research should focus on optimizing arterial grafting strategies in CABG.
Aim:
The aim of this study was to compare long-term all-cause mortality between patients receiving percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) using multiple (MAG) or single arterial grafting (SAG).
Methods And Results:
The current study is a post hoc analysis of the SYNTAX Extended Survival Study, which compared PCI with CABG in patients with three-vessel (3VD) and/or left main coronary artery disease (LMCAD) and evaluated survival with ≥10 years of follow-up. The primary endpoint was all-cause mortality at maximum follow-up (median 11.9 years) assessed in the as-treated population. Of the 1743 patients, 901 (51.7%) underwent PCI, 532 (30.5%) received SAG, and 310 (17.8%) had MAG. At maximum follow-up, all-cause death occurred in 305 (33.9%), 175 (32.9%), and 70 (22.6%) patients in the PCI, SAG, and MAG groups, respectively (P < 0.001). Multiple arterial grafting [adjusted hazard ratio (HR) 0.66, 95% confidence interval (CI) 0.49-0.89], but not SAG (adjusted HR 0.83, 95% CI 0.67-1.03), was associated with significantly lower all-cause mortality compared with PCI. In patients with 3VD, both MAG (adjusted HR 0.55, 95% CI 0.37-0.81) and SAG (adjusted HR 0.68, 95% CI 0.50-0.91) were associated with significantly lower mortality than PCI, whereas in LMCAD patients, no significant differences between PCI and MAG (adjusted HR 0.90, 95% CI 0.56-1.46) or SAG (adjusted HR 1.11, 95% CI 0.81-1.53) were observed. In patients with revascularization of all three major myocardial territories, a positive correlation was observed between the number of myocardial territories receiving arterial grafts and survival (Ptrend = 0.003).
Conclusion:
Our findings suggest that MAG might be the more desirable configuration for CABG to achieve lower long-term all-cause mortality than PCI in patients with 3VD and/or LMCAD.
Trial Registration:
Registered on clinicaltrial.gov. SYNTAXES: NCT03417050 (https://clinicaltrials.gov/ct2/show/NCT03417050); SYNTAX: NCT00114972 (https://www.clinicaltrials.gov/ct2/show/NCT00114972).
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