Optimal revascularization strategy for patients with multivessel coronary artery disease has been, and remains, a topic of controversy. Rapid technological advances in percutaneous coronary interventions (PCI) such as the introduction of new devices and highly maneuverable stents have made it possible to attempt complex lesions with great procedural success rates. Furthermore, drug-eluting stents (DES) offered about a 50% decrease in restenosis, reducing the need for repeat revascularization, which has been the Achilles heel of PCI. Surgical techniques have also evolved over the past several years, reducing surgical complications while treating higherrisk patients (off-pump bypass surgery, minimally invasive bypass surgery, etc.).
The data available for comparing multivessel PCI to coronary artery bypass graft surgery (CABG) can be broadly divided into randomized clinical trials, and registry data. Several randomized studies have compared PCI with CABG in multivessel coronary artery disease (CAD), which can be categorized into those comparing PTCA alone with CABG (BARI, CABRI, RITA, EAST,GABI, ERACI),1,2,10–12,14 PTCA and bare-metal stenting (BMS) with CABG (ARTS I, SOS, ERACI II, AWESOME),3,4,8,9 and PTCA and DES with CABG (ARTS II, ERACI III).6,18 The registries include the New York registry, Duke Registry and the Cleveland Clinic registry.5,7,17
Data from the majority of the randomized clinical trials showed that CABG provides more effective angina relief and less need for repeat revascularization, but offered no survival benefit over PCI, except in patients with diabetes. The advent of stenting reduced repeat revascularization from 54% in BARI1 to 28% in ERACI II,3 and 30% in ARTS.4 The use of DES further reduced the rate of repeat revascularization. Target vessel revascularization was comparable to CABG in the ARTS II18 and ERACI III6 studies. Recently published 3-year data from the ERACI III6 group reveals a major adverse cardiac and cerebrovascular events (MACCE) rate of 22.7%, equal to that of CABG.
Data showing mortality benefit for CABG in multivessel CAD compared to PCI are mainly derived from registries, with the New York registry data7 showing a mortality rate reduction of at least 25% across all anatomic subgroups. The SOS8 was a randomized trial that also reported a mortality benefit for surgery over 1 year, but with an exceedingly low death rate in the CABG arm (2% vs. 5%; p = 0.01). Meta-analysis of 13 randomized clinical trials15 also demonstrated a 1.9% survival advantage for CABG over PCI.
Randomized, controlled trials enrolled smaller numbers of patients, and some were underpowered to detect survival benefit. Registries do have the advantage of analyzing large number of real-life patients, but they provide observational data usually affected by selection bias.
In this edition of the Journal of Invasive Cardiology, Varani et al present data comparing multiple DES PCI and surgical revascularization in patients with multivessel CAD. Although this study is not randomized and has a relatively small sample size, it does include real-life patients, has high utilization of glycoprotein IIb/IIIa inhibitors and provides cost analysis data. This study appears to support the 1-year data from ARTS II and demonstrates the safety, technical feasibility, high procedural success, beneficial cost profile, and good early- and medium-term results for patients treated with multiple DES PCI. Overall survival and major adverse cardiac events (MACE) were not significantly different between the two groups. TVR, while reduced in DES compared to historical BMS, was still higher than CABG. Of note, the lesions attempted in the PCI group were mostly B2/C lesions with a high percentage of left anterior descending artery interventions, even including some left main interventions. This study does not provide long-term follow up and does not address the issue of very late stent thrombosis. While this study does provide additional important information, its limitations should be acknowledged: small sample size that was selected from a larger cohort and matched between the two arms, the retrospective nature of the analysis, and the lack of controlled randomization. This emphasizes the need for conducting large randomized trials with long-term follow up in this rapidly evolving and controversial field. SYNTAX16 and FREEDOM trials should provide further clarity.
PCI and CABG should be considered complementary rather than competitive revascularization strategies. There is no substitute for sound clinical judgment that takes into account the patient’s overall clinical profile, functionality, comorbidities, as well as the patient’s coronary anatomy. Furthermore, unbiased incorporation of available data allows for optimal decision making for the individual patient. Ultimately, taking the best of both strategies (hybrid revascularization procedures), optimizing medical therapy and initiating lifestyle modification may provide the optimal outcome for our patients.
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