LMS and multivessel disease – stents or surgery?04 March 2009
By: Andrew Wiper
Multiple trials have compared PCI with bare metal stents against CABG in the setting of multivessel disease (e.g. MASS 11, ERACI-II, AWESOME, ARTS 1). They have shown similar survival rates at 5 years but with a higher revascularisation rate among those treated with bare metal stents. The SOS study (and others) have shown a significant long term survival advantage with CABG.
A large meta-analysis comparing drug eluting stents with bare metal stents showed significant reductions in the need for repeat revascularisation with a similar MACE rate¹.
Advancements in intra-arterial stent design, delivery and deployment have made PCI with drug eluting stents more feasible for increasingly complex coronary lesions. There is however scant data from randomised trials when evaluating PCI with drug eluting stents against CABG in both three-vessel and left main stem disease.
The SYNTAX trial randomly assigned 1800 patients (in a 1:1 ratio) with previously untreated multivessel and/or left main coronary artery disease to undergo CABG or PCI with Taxus Express paclitaxel-eluting stents. 17 countries participated in the study, in both Europe and the US. Exclusion criteria were acute myocardial infarction, previous intervention and concomitant surgery.
In all these patients, a local interventional cardiologist and cardiothoracic surgeon at each site agreed that the equivalent anatomical revascularisation could be achieved with either approach.
The primary end point – namely death from any cause, stroke, myocardial infarction or repeat revascularisation – were evaluated during the 12 month period after randomisation.
Patients in the two groups had similar preoperative characteristics.
Rates of major adverse cardiac or cerebrovascular events at 12 months (the primary end point) were significantly higher in the PCI group (17.8%, vs 12.4% for CABG; p=0.002) mainly due to the increased rate of repeat revascularisation (13.5% vs 5.9%, p<0.001).
The rate of stroke was significantly higher with CABG than with PCI at 12 months (2.2% vs 0.6% for PCI, p=0.003) even though both groups were well matched with regards to carotid artery disease and risk factors for stroke.
A possible hypothesis is that the higher incidence of stroke in CABG may be attributable to suboptimal medical therapy (e.g. statins, ACE inhibitors, anti-platelet therapy) post surgery.
The 12 month rates of symptomatic graft occlusion and stent thrombosis were similar, with most cases of stent thrombosis occurring within 30 days post PCI.
With left main stem disease, the rates of major adverse cardiac or cerebrovascular events were similar at 12 months (13.7% vs 15.8%, CABG vs PCI) although again the incidence of repeat revascularisation was higher in the PCI group (11.8%, vs 6.5% in CABG, p=0.02).
With three vessel disease in the absence of left main stem disease, the 12 month rate of major adverse cardiac or cerebrovascular events was higher in the PCI group as compared with CABG (19.2% vs 11.5%, p<0.001), as was the rate of repeat revascularisation (14.6% vs 5.5%, p<0.001).
The authors concluded “that CABG, as compared with PCI, is associated with a lower rate of major adverse cardiac or cerebrovascular events at 1 year among patients with three-vessel or left main coronary artery disease (or both) and should remain the standard of care for such patients”.
However if the revascularisation parameter is removed from the equation, at 12 months the rates of death and myocardial infarction were similar between the two groups.
Certainly, the more complex the coronary artery disease, the more compelling is the evidence for CABG over PCI, demonstrated in all subsets of patients.
However, if a patient wants to reduce their risk of having a stroke and doesn’t want a sternotomy with the associated recovery time, then there is certainly a place for PCI with drug eluting stents, with an acknowledged increased risk of having a redo procedure.
1) Stettler C, Wandel S, Allemann S, et al. Outcomes associated with drug-eluting and bare-metal stents: a collaborative network meta-analysis. Lancet 2007;370:937-948.
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