Coronary artery bypass surgery and percutaneous transluminal coronary angioplasty in patients with multivessel disease

Since its introduction in the early 1970s, coronary artery bypass grafting (CABG) surgery has been proven to relief anginal symptoms in patients with severe myocardial ischemia. Percutaneous coronary intervention (PCI) was introduced in clinical practice at the end of the 1970s and this treatment has also been established to be effective. PCI has now surpassed CABG as the most common means for treating coronary artery disease (CAD). However, restenosis remains its Achille's heel. Until the mid-1990s, a coronary reintervention was needed in 35% to 40% of the patients. Since then, interventional techniques and technology have evolved with improved success in more complex and anatomical settings, and restenosis has been now consistently decreased to around 20%. Despite all these improvements, the incidence of restenosis, especially in the 1(st) year, is still an important limitation to PCI. The major determinants of restenosis are elastic recoil, negative vessel remodeling and neointimal proliferation as a response to vessel injury induced by angioplasty devices. The use of conventional stents has provided an efficient method to face the first 2 problems, but neointimal proliferation is not affected by stenting. A new approach consists of using the stent as a drug carrier to the target site in order to inhibit restenosis. The first results of utilization of these fascinating drug-eluting stents (DES) to treat relatively simple lesions are very promising, but further analyses for more complex lesions such as those commonly found in daily practice are needed before any definitive conclusions can be made.     

Trials comparing coronary artery bypass grafting with percutaneous transluminal coronary angioplasty and primary stent implantation in patients with multivessel coronary artery disease

With marked improvements in stent technology as adjunct to balloon angioplasty for multivessel coronary disease, several newer trials are currently in progress reviewing the optimal revascularization strategy. This review provides background from older studies and addresses the current progress and design of these newer trials.     

Patient preferences for coronary artery bypass graft surgery or percutaneous intervention in multivessel coronary artery disease

Objectives: Determine if patients prefer multivessel percutaneous coronary intervention (mv‐PCI) over coronary artery bypass graft surgery (CABG) for treatment of symptomatic multivessel coronary artery disease (mv‐CAD) despite high 1‐year risk. Background: Patient risk perception and preference for CABG or mv‐PCI to treat medically refractory mv‐CAD are poorly understood. We hypothesize that patients prefer mv‐PCI instead of CABG even when quoted high mv‐PCI risk. Methods: 585 patients and 31 physicians were presented standardized questionnaires with a hypothetical scenario describing chest pain and medically refractory mv‐CAD. CABG or mv‐PCI was presented as treatment options. Risk scenarios included variable 1‐year risks of death, stroke, and repeat procedures for mv‐PCI and fixed risks for CABG. Participants indicated their preference of revascularization method based on the presented risks. We calculated the odds that patients or physicians would favor mv‐PCI over CABG across a range of quoted risks of death, stroke, and repeat procedures. Results: For nearly all quoted risks, patients preferred mv‐PCI over CABG, even when the risk of death was double the risk with CABG or the risk of repeat procedures was more than three times that for CABG (P < 0.0001). Compared to patients, physicians chose mv‐PCI less often than CABG as the risk of death and repeat procedures increased (P < 0.001 and P = 0.004, respectively). Conclusion: Patients favor mv‐PCI over CABG to treat mv‐CAD, even if 1‐year risks of death and repeat procedures far exceed risk with CABG. Physicians are more influenced by actual risk and prefer mv‐PCI less than patients despite similarly quoted 1‐year risks. © 2013 Wiley Periodicals, Inc.     

Meta-analysis of percutaneous coronary intervention versus coronary artery bypass graft surgery in patients with diabetes and left main and/or multivessel coronary artery disease

The optimal coronary revascularization strategy for patients with diabetes and left main and/or multivessel disease is undetermined. The aim of our study was to evaluate percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) in those patients. We identified 13 articles, published before October 2011, enrolling 6992 patients, whose follow-up period ranged from 1 to 5 years. Patients with PCI had a significant reduction in cerebral vascular attack (CVA) (OR, 0.29; 95 % CI, 0.16–0.51; p < 0.0001, I ² = 0 %) as compared with CABG, whereas there was a fourfold increased risk of repeat revascularization associated with PCI even using drug-eluting stent (OR, 4.44; 95 % CI, 3.42–5.78; Χ² = 4.92, p < 0.00001, I ² = 0 %). The overall mortality (OR, 0.97; 95 % CI, 0.81–1.15; p = 0.70, I ² = 0 %) was comparable between the PCI and CABG. However, in subgroup analysis, the composite outcome (death/myocardial infarction/CVA) was significantly reduced in favor of DES implantation (OR, 0.79; 95 % CI, 0.63–0.99; Χ² = 1.07, p = 0.04, I ² = 0 %). Our study confirmed the cerebral vascular benefits of PCI by significantly reducing CVA risks, and the composite outcome was better in patients undergoing PCI with drug-eluting stent, despite a higher repeat revascularization rate. It poses imperative demands for future prospective randomized studies to define the optimal strategy in patients with diabetes and left main and/or multivessel disease.     

Potential shift from coronary bypass surgery to percutaneous coronary intervention for multivessel disease and its economic impact in the drug-eluting stent era

BACKGROUND: Drug-eluting stents (DES) may promote percutaneous coronary intervention (PCI) procedures in patients traditionally referred for coronary artery bypass graft (CABG) surgery and may save money. OBJECTIVES: The purpose of the present study was to quantify the potential shift from CABG surgery to multivessel PCI in the DES era and to model the economic consequences. METHODS: Based on predefined criteria, the feasibility of PCI was evaluated in patients with multivessel coronary artery disease who underwent CABG surgery before the availability of DES at the Centre Hospitalier de l'Université de Montréal's Notre-Dame Hospital (Montreal, Quebec). Modelling was used to evaluate the potential cost savings using multivessel PCI instead of CABG surgery. Equal one-year outcomes in both groups were assumed, with the exception of a 10% repeat revascularization (RR) rate in the DES group and a 4% RR rate in the CABG group. The impact of those assumptions was evaluated using 1000 Monte Carlo simulations. RESULTS: The authors retrospectively evaluated that, of 289 patients who underwent CABG without concomitant valve surgery between January and December 2003, only 22 patients (8%) were good candidates for multivessel DES implantation. The procedures would have involved an average of 3.6 DES per patient. The average cost per revascularization procedure was $14,402 with surgery and $11,220 for multivessel DES implantation (using $2,200 DES), leading to a savings of $3,182 per patient. However, after including RR procedures, PCI would only have been associated with savings of $812 per surgery avoided. Monte Carlo analysis revealed that surgery may be less expensive than PCI in 36% of patients. CONCLUSIONS: Most patients who underwent CABG surgery in 2003 were retrospectively judged to be ineligible for multivessel PCI with DES. In the rare eligible patient, multivessel PCI with DES is not expected to produce savings to health care costs in Canada unless the DES purchase cost continues to decrease.     

药物洗脱支架治疗糖尿病多支冠脉病变

目的 探讨药物洗脱支架治疗糖尿病多支冠脉病变患者的安全性和可行性,并与冠脉旁路移植术的疗效进行比较.方法 150例糖尿病多支冠脉病变患者,84例行药物洗脱支架置入术(DES组),66例行冠脉旁路移植术(CABG组).比较两组住院期和随访期不良心血管事件(死亡、心肌梗死、再次血管重建术和脑血管意外)的发生情况.结果 两组的大多数临床和冠脉病变特征相似,CABG组左主干病变(30%比4%,P=0.001)和三支病变(70%比54%,P=0.045)显著增多,完全血管重建化率更高(82%比67%,P=0.037).住院期CABG组术后病死率显著增高(6.1%比0%,P=0.022),但两组总体不良心血管事件发生率仍相似(2.4%比9.1%,P=0.069).在平均(18±8)个月随访期,DES组再次血管重建化率显著增加(13.1%比3.0%,P=0.03),导致总体不良心血管事件发生率增高(21.4%比9.1%,P=0.041),其中相当部分(45%)由于病变进展所致.结论 药物洗脱支架置入术应用在糖尿病多支冠脉病变患者中安全可行,缩小了再次血管重建化发生率上与冠脉旁路移植术的差距.     

Cost-effectiveness of bypass surgery versus stenting in patients with multivessel coronary artery disease

PURPOSE: To compare the cost-effectiveness of surgical and angioplasty-based coronary artery revascularization techniques, in particular, angioplasty with primary stenting. METHODS: We used data from the Study of Economics and Quality of Life, a substudy of the Bypass Angioplasty Revascularization Investigation (BARI), to measure the outcomes and costs of angioplasty and bypass surgery in patients with multivessel coronary artery disease who had not undergone prior coronary artery revascularization. Using a Markov decision model, we updated the outcomes and costs to reflect technology changes since the time of enrollment in BARI, and projected the lifetime costs and quality-adjusted life-years (QALYs) for the two procedures from the time of initial treatment through death. We accounted for the effects of improved procedural safety and efficiency, and prolonged therapeutic effects of both surgery and stenting. This study was conducted from a societal perspective. RESULTS: Surgical revascularization was less costly and resulted in better outcomes than catheter-based intervention including stenting. It remained the preferred strategy after adjusting the stent outcomes to eliminate the costs and events associated with target lesion restenosis. Among angioplasty-based strategies, primary stent use cost an additional 189,000 US dollars per QALY gained compared with a strategy that reserved stent use for treatment of suboptimal balloon angioplasty results. CONCLUSION: Bypass surgery results in better outcomes than angioplasty in patients with multivessel disease, and at a lower cost.     

The role of coronary artery bypass surgery versus percutaneous intervention in patients with diabetes and coronary artery disease

Patients with diabetes mellitus (DM) often exhibit a complex coronary anatomy, making coronary revascularization challenging. Coronary artery bypass grafting surgery (CABG) is currently considered the preferred revascularization method in patients with DM and multivessel disease. Percutaneous coronary intervention (PCI) has advanced with new stent generations having been developed in the recent years, but they have not yet been adequately compared against CABG in the population with DM. Comorbidities, such as renal disease and heart failure, lead to worse prognosis following a revascularization procedure and require especial consideration when choosing between CABG versus PCI. The presence of significant left main disease may also impose additional challenges to coronary revascularization, particularly when accompanied by the involvement of multivessel disease. Most of the evidence regarding revascularization in patients with DM is compiled from studies enrolling patients with stable ischemic heart disease, and trials with patients in the acute coronary syndrome setting are lacking.     

药物洗脱支架与冠状动脉旁路移植术治疗冠状动脉多支病变的比较

目的比较药物洗脱支架与冠状动脉旁路移植术治疗冠状动脉复杂多支病变的疗效。方法连续入选行血运重建治疗的冠心病多支病变患者200名,随机分为经皮冠状动脉介入(PCI)组和冠状动脉旁路移植术(CABG)组,每组100例。PCI组和CABG组中分别有合并糖尿病者(糖尿病亚组)27例和25例。观察术后1年内主要心脑血管不良事件(死亡、脑卒中、非致死性心肌梗死、靶血管再次血运重建)、再狭窄、心绞痛复发发生率,血浆肌酸激酶水平和PCI组支架内血栓形成发生率。结果两组患者的基线特征差异无统计学意义。PCI组与CABG组1个月、6个月和1年的主要心脑血管不良事件发生率分别为4.0%、7.0%、12.0%比6.0%、9.0%、15.2%(P>0.05);心绞痛复发率分别为2.0%、4.0%、6.0%比1.0%、3.0%、5.1%(P>0.05)。术后1年再狭窄率分别为11.3%比13.2%(P>0.05)。PCI组术后亚急性血栓形成率1.0%。PCI组和CABG组术后肌酸激酶MB型同工酶升高的患者比例分别为26%比82%(P<0.05)。PCI组糖尿病亚组与CABG组糖尿病亚组1个月、6个月和1年的严重心脑血管不良事件发生率分别为7.4%、11.1%、18.5%比8.0%、16.0%、24.0%(P>0.05)。结论药物洗脱支架时代PCI与CABG治疗冠状动脉多支病变的近、远期疗效相近,对于合并糖尿病的患者同样有效。     

Comparing mortality between coronary artery bypass grafting and percutaneous coronary intervention with drug-eluting stents in elderly with diabetes and multivessel coronary disease

Coronary artery disease is a critical issue that requires physicians to consider appropriate treatment strategies, especially for elderly people who tend to have several comorbidities, including diabetes mellitus (DM) and multivessel disease (MVD). Several studies have been conducted comparing clinical outcomes between percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) in patients with DM and MVD. However, elderly people were excluded in those clinical studies. Therefore, there are no comparisons of clinical outcomes between CABG and PCI in elderly patients with DM and MVD. We compared all-cause mortality between PCI with drug-eluting stents (DES) and CABG in elderly patients with DM and MVD. A total of 483 (PCI; n = 256, CABG; n = 227) patients were analyzed. The median follow-up period was 1356 days (interquartile range of 810–1884). The all-cause mortality rate was not significantly different between CABG and PCI with DES groups. The CABG group had more patients with complex coronary lesions such as three-vessel disease or a left main trunk lesion. Older age, hemodialysis, and reduced LVEF were associated with increased long-term all-cause mortality in a multivariable Cox regression analysis. The rate of all-cause mortality was not significantly different between the PCI and CABG groups in elderly patients with DM and MVD in a single-center study.     

冠心病多支病变雷帕霉素洗脱支架置入与冠状动脉旁路移植术的疗效对比

目的:对比雷帕霉素洗脱支架(SES)置入与冠状动脉旁路移植术(CABO)的近期与中期临床疗效.方法:单中心回顾性连续入选2003年7月～2004年6月期间行择期血运重建的多支冠状动脉病变患者,分为CAB(;组(811例),SES组(251例).随访终点事件包括死亡、心肌梗死、脑卒中和再次血运重建等主要不良心脑血管事件(MACCE).采用Kaplan-Meier方法估计无事件生存率.采用Logistic多元回归方法调整分析治疗对终点事件的相对影响.结果:随访率90.3%.中位随访时间19个月.随访30 d,CABG组MACCE的发生率高于SES组(5.4%: 1.6%,OR 3.66,95%CI 1.26～10.61),CABG组的病死率高于SES组(4.6%:1.2%,OR4.02,95%CI 1.18～13.74).至随访结束,SES组累积病死率低于CAB(;组(3.1%:7.6%,OR 0.44,95%CI0.19～0.99),但再次血运重建率高于CABG组(8.4%:1.5%,OR 6.83,95%CI 3.07～15.19),MACCE 2组间差异无统计学意义.以30 d为分期分析,CABG组30d生存率低于SES组(95.4%;98.8%,P＜0.05),2组30d后生存率差异无统计学意义(97.2%:98.3%,P＞0.05).结论:多支冠状动脉病变CABG与SES置入比较,CABG的30 d病死率高于SES置入,30 d后病死率差异无统计学意义;多支冠状动脉SES置入的中期血运重建率高于CABG.