Key result
PCI with DES linked to ~6.2-fold higher TVR vs. CABG in unprotected LMCA disease.
Why the study?
Data on the long-term (beyond 5-year) comparative results of treatment of unprotected LMCA disease with stent implantation or CABG were limited.
Does percutaneous coronary intervention with stenting provide comparable long-term safety and efficacy to coronary artery bypass grafting in patients with unprotected left main coronary artery disease?
Cohort (n=745)
Does percutaneous coronary intervention with stenting provide comparable long-term safety and efficacy to coronary artery bypass grafting in patients with unprotected left main coronary artery disease?
In patients with unprotected left main coronary artery disease, PCI with BMS or DES offers comparable 5- to 10-year survival and hard clinical outcomes to CABG, at the expense of significantly higher rates of repeat target vessel revascularization.
Answers are grounded in this paper and cite their sources.
May inform Heart Team decisions in LMCA disease; leaves open need for contemporary randomized long-term confirmation.
Objectives This study sought to evaluate the long-term safety and effectiveness of percutaneous coronary intervention (PCI), as compared with coronary artery bypass grafting (CABG), for unprotected left main coronary artery (LMCA) disease. Background Data on the long-term (beyond 5-year) comparative results of treatment of unprotected LMCA disease with stent implantation or CABG are limited. Methods We performed a 10-year clinical follow-up of 350 patients with unprotected LMCA disease who underwent PCI with bare-metal stents (BMS) (n = 100) or CABG (n = 250) from January 1995 to April 1999, and 5-year clinical follow-up of 395 patients with unprotected LMCA disease who underwent PCI with drug-eluting stents (DES) (n = 176) or CABG (n = 219) from January 2003 to May 2004. The primary safety end points were all-cause mortality and the composite of death, Q-wave myocardial infarction (MI), or stroke, and the primary efficacy end point was target vessel revascularization (TVR). Results In the 10-year follow-up cohort of BMS and concurrent CABG, the adjusted risks of death (hazard ratio [HR]: 0.81; 95% confidence interval [CI]: 0.44 to 1.50; p = 0.50) and the composite of death, Q-wave MI, or stroke (HR: 0.92; 95% CI: 0.55 to 1.53; p = 0.74) were similar between the 2 groups. The rate of TVR was significantly higher in the group that received BMS (HR: 10.34; 95% CI: 4.61 to 23.18; p < 0.001). In the 5-year follow-up cohort of DES and concurrent CABG, there was no significant difference in the adjusted risk of death (HR: 0.83; 95% CI: 0.34 to 2.07; p = 0.70) or the risk of the composite outcome (HR: 0.91; 95% CI: 0.45 to 1.83; p = 0.79). The rates of TVR were also higher in the DES group than the CABG group (HR: 6.22; 95% CI: 2.26 to 17.14; p < 0.001). Conclusions For the treatment of unprotected LMCA disease, PCI with stent implantation showed similar long-term mortality and rates of death, Q-wave MI, or stroke. However, stenting, even with DES, was associated with higher rates of repeat revascularization than was CABG.
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Park et al. (2010) conducted a cohort in Unprotected left main coronary artery (LMCA) disease (n=745). Percutaneous coronary intervention (PCI) with bare-metal stents (BMS) or drug-eluting stents (DES) vs. Coronary artery bypass grafting (CABG) was evaluated on Primary safety end points: all-cause mortality and composite of death, Q-wave MI, or stroke; Primary efficacy end point: target vessel revascularization (TVR) (HR 6.22, 95% CI 2.26-17.14, p=<0.001). PCI with DES had similar 5-year mortality (HR 0.83; p=0.70) to CABG in unprotected LMCA disease, but increased target vessel revascularization (HR 6.22; 95% CI 2.26-17.14; p<0.001).
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