percutaneous coronary intervention (PCI)/coronary stent vs CABG
Jump to navigation
Jump to search
Introduction
Comparison of stent-assisted percutaneous transluminal coronary angioplasty (PTCA) versus coronary artery bypass graft (CABG).
Stent or Surgery Trial (SoS)[1]
Median follow-up 2 years
Results:
- combined input of death & Q-wave myocardial infarction (MI) similar in 2 groups (10%)
- all-cause mortality lower in CABG group (2% vs 5%)
- revascularization procedures higher in stent-PTCA group (21% vs 5%)
Outcomes similar with CABG & drug-eluting stent PCI[2]
CABG superior to stenting*[3] (studies did NOT include drug-eluting stents)
mortality similar after 1 year (PCI, 6.6%; CABG, 6.2%)
mortality at 4 years favors CABG (16.4% vs. 20.8%)[7]
CABG superior to drug-eluting stents in patients with diabetes mellitus[8]
- mortality & myocardial infarction lower with CABG
- stroke lower with PCI & drug-eluting stent[8]
CABG superior to PCI in older patients with multivessel disease[7][10]
- CABG superior to PCI in patients with complex multivessel disease[16]
CABG superior to PCI in patients amenable to bypass surgery with
- left main coronary artery disease[27]
- PCI may be appropriate for some patients with left main coronary artery disease
- multivessel disease with severe systolic dysfunction or diabetes mellitus[27]
- CABG is recommended for patients who have left main disease, triple vessel disease, & reduced systolic function, or multivessel disease with involvement of the proximal left anterior descending artery in the presence of diabetes[16]
stenting for left main coronary artery disease with similar outcomes to CABG:
- composite of death, myocardial infarction, stroke
- more frequent need repeat revascularization[5]
- (12.6% vs. 7.5%)[17]
- CABG superior if concurrent 3-vessel disease[5]
- CABG may be superior if left main disease is severe[10]
- higher rates of nonprocedural MI & repeat revascularization with PCI[20]
- after 5-years, all-cause mortality no different between PCI & CABG[24]
- PCI or CABG reasonable for left main coronary artery disease[25]
5 year outcomes similar for composite outcomes of mortality & major cardiovascular event for left main coronary artery disease[19][26]
- composite of all-cause mortality, stroke, or myocardial infarction
- 19% for CABG & 22% for PCI[19]
- all-cause mortality similar for PCI vs CABG for patients with acute coronary syndrome (10.9% vs 11.5%)[26] & 11.3% vs 9.6% without[26]
- ischemia-driven revascularization higher for PCI vs CABG (17% vs 10%)[19]
- study[19] funded by manufacturer of stent,[26] meta-analysis of 4 studies
CABG with mortality benefit at 5 years vs PCI for patients with diabetes mellitus (HR=0.88) & those with a history of smoking [[[A26615|HR]]=0.82)[11]
PCI with slight mortality benefit at 5 years vs CABG for patients without a history of diabetes mellitus, smoking, peripheral artery disease or heart failure[11]
Patients are less likely to be compliant with their medications after CABG than after PCI[9]
Advantage to CABG for total mortality (RR=0.73), incident myocardial infarction (RR=0.58), & repeat revascularization (RR=0.29) for multivessel disease[14]
- patients with multivessel disease and reduced LVEF should undergo CABG rather than PCI[2]
- no effect of diabetes mellitus[14]
long-term mortality similar with CABG vs PCI with everolimus- eluting stent for non-diabetic patients with multivessel disease[15]
- MI rates may be higher after PCI
- PCI may offer early safety benefits for stroke, hemorrhage
- greater risk of need for revascularization with PCI
CABG superior to PCI with coronary stent in patients with multivessel disease &/or diabetes mellitus[16][18]
PCI may be preferable to CABG for single-vessel disease even in patients with diabetes mellitus
CABG may be preferable to PCU for ischemic cardiomyopathy with low LVEF[21]
Coronary revascularization declining in US, CABG more so than stenting[6]
Among older adults CABG vs PCI not different in post-procedural cognitive effects[22]
major cardiovascular events 1 year after procedure was higher with fractional flow reserve-guided PCI than with CABG[23]
Additional terms
- artery
- bypass
- coronary
- coronary stent/coronary stenting
- percutaneous coronary intervention (PCI)
- tissue graft
References
- ↑ 1.0 1.1 Journal Watch 23(1):3, 2003 The SoS Investigators, Lancet 360:965, 2002 O'Neill WW & Grines CL, Lancet 360:961, 2002
- ↑ 2.0 2.1 2.2 Chieffo A et al, Percutaneous treatment with drug-eluting stent implantation versus bypass surgery for unprotected left main stenosis: A single-center experience. Circulation 2006; 113:2542 PMID: https://www.ncbi.nlm.nih.gov/pubmed/16717151
Kereiakes DJ and Faxon DP Left main coronary revascularizarion at the crossroads. Circulation 2006; 113:2480 PMID: https://www.ncbi.nlm.nih.gov/pubmed/16735688 - ↑ 3.0 3.1 Aziz O et al, Meta-analysis of minimally invasive internal thoracic artery bypass versus percutaneous revascularization for isolated lesions of the left anterior descending artery. BMJ 2007, 334:617 PMID: https://www.ncbi.nlm.nih.gov/pubmed/17337458
Rao C et al, Cost effectiveness analysis of minimally invasive internal thoracic artery bypass versus percutaneous revascularisation for isolated lesions of the left anterior descending artery. BMJ 2007, 334:621 PMID: https://www.ncbi.nlm.nih.gov/pubmed/17337457 - ↑ Cohen DJ et al Quality of Life after PCI with Drug-Eluting Stents or Coronary-Artery Bypass Surgery N Engl J Med 2011; 364:1016-1026 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/21410370 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1001508
- ↑ 5.0 5.1 5.2 5.3 Park SJ et al. Randomized trial of stents versus bypass surgery for left main coronary artery disease. N Engl J Med 2011 Apr 4; PMID: https://www.ncbi.nlm.nih.gov/pubmed/21463149
- ↑ 6.0 6.1 Epstein AJ et al. Coronary revascularization trends in the United States, 2001-2008. JAMA 2011 May 4; 305:1769. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21540420
- ↑ 7.0 7.1 7.2 Weintraub WS et al. Comparative effectiveness of revascularization strategies. N Engl J Med 2012 Mar 27 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/22452338 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1110717
- ↑ 8.0 8.1 8.2 Farkouh ME et al for the FREEDOM Trial Investigators Strategies for Multivessel Revascularization in Patients with Diabetes N Engl J Med 2012 Nov 4 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23121323 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1211585
Hlatky MA. Compelling evidence for coronary-bypass surgery in patients with diabetes. N Engl J Med 2012 Nov 4 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23121324 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMe1212278 - ↑ 9.0 9.1 Hlatky MA et al. Use of medications for secondary prevention after coronary bypass surgery compared with percutaneous coronary intervention. J Am Coll Cardiol 2013 Jan 22; 61:295. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23246391
- ↑ 10.0 10.1 10.2 Mohr FW et al. Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial. Lancet 2013 Feb 23; 381:629 PMID: https://www.ncbi.nlm.nih.gov/pubmed/23439102
Taggart DP. CABG or stents in coronary artery disease: End of the debate? Lancet 2013 Feb 23; 381:605. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23439089 - ↑ 11.0 11.1 11.2 Hlatky MA et al Comparative Effectiveness of Multivessel Coronary Bypass Surgery and Multivessel Percutaneous Coronary Intervention: A Cohort Study. Ann Intern Med. 23 April 2013 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23609014 <Internet> http://annals.org/article.aspx?articleid=1679804
- ↑ Chaitman BR, Hardison RM, Adler D et al The Bypass Angioplasty Revascularization Investigation 2 Diabetes randomized trial of different treatment strategies in type 2 diabetes mellitus with stable ischemic heart disease: impact of treatment strategy on cardiac mortality and myocardial infarction. Circulation. 2009 Dec 22;120(25):2529-40. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19920001
- ↑ Sobel BE. Coronary revascularization in patients with type 2 diabetes and results of the BARI 2D trial. Coron Artery Dis. 2010 May;21(3):189-98. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20308880
- ↑ 14.0 14.1 14.2 Sipahi I et al Coronary Artery Bypass Grafting vs Percutaneous Coronary Intervention and Long-term Mortality and Morbidity in Multivessel Disease. Meta-analysis of Randomized Clinical Trials of the Arterial Grafting and Stenting Era. JAMA Intern Med. Published online December 02, 2013 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24296767 <Internet> http://archinte.jamanetwork.com/article.aspx?articleid=1783046
- ↑ 15.0 15.1 Park SJ et al Trial of Everolimus-Eluting Stents or Bypass Surgery for Coronary Disease. N Engl J Med. March 16, 2015 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25774645 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1415447
Bangalore S et al Everolimus-Eluting Stents or Bypass Surgery for Multivessel Coronary Disease. N Engl J Med. March 16, 2015 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25775087 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1412168
Harrington RA Selecting Revascularization Strategies in Patients with Coronary Disease. N Engl J Med. March 16, 2015 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25774977 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMe1501045
NEJM Quicktime Video http://www.nejm.org/action/showMediaPlayer?doi=10.1056/NEJMoa1415447&aid=NEJMoa1415447_attach_1 - ↑ 16.0 16.1 16.2 16.3 Medical Knowledge Self Assessment Program (MKSAP) 17, 18, 19. American College of Physicians, Philadelphia 2015, 2018, 2022
- ↑ 17.0 17.1 17.2 17.3 Stone GW, Sabik JF, Serruys PW et al. Everolimus-eluting stents or bypass surgery for left main coronary artery disease. N Engl J Med 2016 Oct 31 PMID: https://www.ncbi.nlm.nih.gov/pubmed/27797291
Braunwald E. Treatment of left main coronary artery disease. N Engl J Med 2016 Oct 31 PMID: https://www.ncbi.nlm.nih.gov/pubmed/27797298 - ↑ 18.0 18.1 Head SJ, Milojevic M, Daemen, et al. Mortality after coronary artery bypass grafting versus percutaneous coronary intervention with stenting for coronary artery disease: A pooled analysis of individual patient data. Lancet 2018 Mar 10; 391:939. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/29478841 <Internet> http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30423-9/fulltext
Bhatt DL. CABG the clear choice for patients with diabetes and multivessel disease. Lancet 2018 Mar 10; 391:913; <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/29478842 <Internet> http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30424-0/fulltext - ↑ 19.0 19.1 19.2 19.3 19.4 Stone GW, Kappetein AP, Sabik JF et al Five-Year Outcomes after PCI or CABG for Left Main Coronary Disease. N Engl J Med. Sept 28, 2019 PMID: https://www.ncbi.nlm.nih.gov/pubmed/31562798 https://www.nejm.org/doi/full/10.1056/NEJMoa1909406
- ↑ 20.0 20.1 Herrmann HC Left Main Coronary Artery Disease: PCI vs. CABG. Journal Watch. Informing Practice. Jan 14, 2020 https://www.jwatch.org/na50616/2020/01/14/left-main-coronary-artery-disease-pci-vs-cabg
- ↑ 21.0 21.1 Sun LY, Gaudino M, Chen RJ et al Long-term Outcomes in Patients With Severely Reduced Left Ventricular Ejection Fraction Undergoing Percutaneous Coronary Intervention vs Coronary Artery Bypass Grafting. JAMA Cardiol. 2020;5(6):631-641 PMID: https://www.ncbi.nlm.nih.gov/pubmed/32267465 Free PMC article https://jamanetwork.com/journals/jamacardiology/fullarticle/2763557
Velazquez EJ Percutaneous Coronary Intervention or Coronary Artery Bypass Grafting to Treat Ischemic Cardiomyopathy? JAMA Cardiol. 2020;5(6):641-642 PMID: https://www.ncbi.nlm.nih.gov/pubmed/32267462 https://jamanetwork.com/journals/jamacardiology/fullarticle/2763556 - ↑ 22.0 22.1 Whitlock EL, Diaz-Ramirez LG, Smith AK et al Association of Coronary Artery Bypass Grafting vs Percutaneous Coronary Intervention With Memory Decline in Older Adults Undergoing Coronary Revascularization. JAMA. 2021;325(19):1955-1964 PMID: https://www.ncbi.nlm.nih.gov/pubmed/34003225 https://jamanetwork.com/journals/jama/fullarticle/2779992
- ↑ 23.0 23.1 Fearon WF, Zimmermann FM, De Bruyne B et al. Fractional Flow Reserve - Guided PCI as compared with coronary bypass surgery. N Engl J Med 2021 Nov 4; [e-pub]. PMID: https://www.ncbi.nlm.nih.gov/pubmed/34735046 https://www.nejm.org/doi/10.1056/NEJMoa2112299
- ↑ 24.0 24.1 Sabatine MS, Bergmark BA, Murphy SA et al. Percutaneous coronary intervention with drug-eluting stents versus coronary artery bypass grafting in left main coronary artery disease: An individual patient data meta-analysis. Lancet. 2021 Nov 12:S0140-6736(21)02334-5 PMID: https://www.ncbi.nlm.nih.gov/pubmed/34793745 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)02334-5/fulltext
- ↑ 25.0 25.1 Gaba P, Christiansen EH, M, Nielsen PH et al Percutaneous Coronary Intervention vs Coronary Artery Bypass Graft Surgery for Left Main Disease in Patients With and Without Acute Coronary Syndromes. A Pooled Analysis of 4 Randomized Clinical Trials. JAMA Cardiol. Published online May 31, 2023 PMID: https://www.ncbi.nlm.nih.gov/pubmed/37256598 https://jamanetwork.com/journals/jamacardiology/fullarticle/2805580
- ↑ 26.0 26.1 26.2 26.3 26.4 Gaba P, Christiansen EH, Nielsen PH et al Percutaneous Coronary Intervention vs Coronary Artery Bypass Graft Surgery for Left Main Disease in Patients With and Without Acute Coronary Syndromes. A Pooled Analysis of 4 Randomized Clinical Trials. JAMA Cardiol. 2023;8(7):631-639 PMID: https://www.ncbi.nlm.nih.gov/pubmed/37256598 PMCID: PMC10233454 (available on 2024-05-31) https://jamanetwork.com/journals/jamacardiology/fullarticle/2805580
- ↑ 27.0 27.1 27.2 Virani SS, Newby LK, Arnold SV et al 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation. 2023. Jul 20. PMID: https://www.ncbi.nlm.nih.gov/pubmed/37471501 Free Article. Review https://www.ahajournals.org/doi/abs/10.1161/CIR.0000000000001168
Rao SV, Reynolds HR, Hochman JS. Chronic Coronary Disease Guidelines Circulation. 2023. Jul 20. PMID: https://www.ncbi.nlm.nih.gov/pubmed/37471475 Free article https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.123.064623