CABG vs PCI: Outcomes With Multiple Arterial Bypass Grafting
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.
The choice of optimal coronary revascularization method, particularly in the case of multivessel coronary artery disease (CAD), is a vigorously debated question that is of considerable importance to patients, clinicians, regulatory agencies, as well as third-party payers. Despite multiple methodological drawbacks of the related comparative studies, the near-uniform equivalence of long-term survival (~5 years) with coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI) has resulted in a dramatic increase in the rate of PCI at the expense of a substantial decrease in CABG volumes. Over the past decade, this debate has intensified with the introduction of drug-eluting stents (DES) as the new standard of care for PCI given their well-documented reduced restenosis rates and associated need for target vessel revascularization as compared with the rates of restenosis and target vessel revascularization for bare-metal stents (BMS). Counterintuitively, however, the lower target vessel revascularization rates have not resulted in improved long-term survival or myocardial infarction rates with DES in most trials. This is while a number of "real-world" observational studies in multivessel CAD patients have suggested improved long-term mortality with DES (e.g.,.)
Randomized controlled trials and large observational studies focusing on multivessel CAD have uniformly associated CABG with significantly less need for coronary reinterventions, and most suggest modestly enhanced intermediate survival for CABG versus either DES-PCI or BMS-PCI. Moreover, the magnitude of the CABG advantage seems to depend on the extensiveness of the coronary disease and is largest for higher complexity cases with intermediate or high SYNTAX (Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery) scores. Notably, this reported superiority of CABG is based on predominantly "conventional" single arterial coronary artery bypass graft (SA-CABG) as the preferred surgical method. SA-CABG, achieved mostly with the left internal thoracic artery (LITA) to left anterior descending (LAD) graft plus additional vein grafts, is the most common form of bypass surgery, but it may likely represent suboptimal surgical strategy. Indeed, compelling evidence has rapidly accumulated over the past decade suggesting a second arterial graft (i.e., multiarterial coronary artery bypass graft [MA-CABG]), most commonly involving the right internal thoracic artery or radial artery, improves intermediate and long-term outcomes substantially compared with those of SA-CABG.
Presently, there are no studies comparing intermediate-to-late outcomes (>5 years) of the presumed best percutaneous approach, or DES-PCI, to that of the presumed optimal surgical revascularization strategy, or MA-CABG. We thus have studied the hypothesis that, in patients with multivessel CAD, MA-CABG surgery will substantially and significantly extend the mortality and reintervention outcomes advantage observed with conventional SA-CABG over that of PCI, irrespective of stent type (BMS or DES). If true, such a finding has the potential to substantially reshape the debate regarding the optimal choice for treatment of multivessel CAD.
Abstract and Introduction
Abstract
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.
Introduction
The choice of optimal coronary revascularization method, particularly in the case of multivessel coronary artery disease (CAD), is a vigorously debated question that is of considerable importance to patients, clinicians, regulatory agencies, as well as third-party payers. Despite multiple methodological drawbacks of the related comparative studies, the near-uniform equivalence of long-term survival (~5 years) with coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI) has resulted in a dramatic increase in the rate of PCI at the expense of a substantial decrease in CABG volumes. Over the past decade, this debate has intensified with the introduction of drug-eluting stents (DES) as the new standard of care for PCI given their well-documented reduced restenosis rates and associated need for target vessel revascularization as compared with the rates of restenosis and target vessel revascularization for bare-metal stents (BMS). Counterintuitively, however, the lower target vessel revascularization rates have not resulted in improved long-term survival or myocardial infarction rates with DES in most trials. This is while a number of "real-world" observational studies in multivessel CAD patients have suggested improved long-term mortality with DES (e.g.,.)
Randomized controlled trials and large observational studies focusing on multivessel CAD have uniformly associated CABG with significantly less need for coronary reinterventions, and most suggest modestly enhanced intermediate survival for CABG versus either DES-PCI or BMS-PCI. Moreover, the magnitude of the CABG advantage seems to depend on the extensiveness of the coronary disease and is largest for higher complexity cases with intermediate or high SYNTAX (Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery) scores. Notably, this reported superiority of CABG is based on predominantly "conventional" single arterial coronary artery bypass graft (SA-CABG) as the preferred surgical method. SA-CABG, achieved mostly with the left internal thoracic artery (LITA) to left anterior descending (LAD) graft plus additional vein grafts, is the most common form of bypass surgery, but it may likely represent suboptimal surgical strategy. Indeed, compelling evidence has rapidly accumulated over the past decade suggesting a second arterial graft (i.e., multiarterial coronary artery bypass graft [MA-CABG]), most commonly involving the right internal thoracic artery or radial artery, improves intermediate and long-term outcomes substantially compared with those of SA-CABG.
Presently, there are no studies comparing intermediate-to-late outcomes (>5 years) of the presumed best percutaneous approach, or DES-PCI, to that of the presumed optimal surgical revascularization strategy, or MA-CABG. We thus have studied the hypothesis that, in patients with multivessel CAD, MA-CABG surgery will substantially and significantly extend the mortality and reintervention outcomes advantage observed with conventional SA-CABG over that of PCI, irrespective of stent type (BMS or DES). If true, such a finding has the potential to substantially reshape the debate regarding the optimal choice for treatment of multivessel CAD.
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