AJC: For left main disease, PCI with DES is safe alternative to CABG

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For patients with unprotected left main coronary artery (ULMCA) disease, PCI with drug-eluting stents (DES) could be a plausible alternative to CABG, based on results of a study published in the April 15 issue of the American Journal of Cardiology.

Michael S. Lee, MD, of the University of California, Los Angeles, and colleagues evaluated the safety and efficacy of PCI with DES on 2,905 patients with ULMCA disease at eight clinical sites across the U.S.

According to the authors, the American College of Cardiology (ACC) and the American Heart Association (AHA) currently recommend CABG as the primary treatment for patients with ULMCA disease because PCI can often lead to revascularization and restenosis. In addition, the current guidelines read that PCI should be performed only when patients are poor candidates for CABG.

For the study, researchers utilized data from 2000 to 2009 AHA, ACC and Transcatheter Cardiovascular Therapeutics meetings for clinical trials that compared CABG and DES in ULMCA disease and that had a follow up of at least 12 years. Eight studies met these criteria—two randomized controlled trials and six meta-analysis, observational trials.

Of the 2,905 patients evaluated, 1,669 patients underwent CABG while 1,236 underwent PCI with DES.

According to the researchers, the CABG group had a higher proportion of males, hypertension and MI than the PCI with DES group, 76 versus 69 percent, 66 versus 61 percent and 16 versus 11 percent, respectively.

Researchers looked at primary endpoints including rates of mortality, composite death, MI or stroke and target vessel revascularization.

Results showed that at one-year follow-up, rates of mortality did not significantly differ between the CABG and DES groups, nor did the rates of composite death, MI or stroke. However, patients in the DES group saw higher rates of target vessel revascularization due to artery re-clogging, but these rates were not reported in all studies.

"There are benefits and risks to both procedures and our analysis shows that for select patients, drug-eluting stenting may be a good alternative," Lee said.

The researchers said that limitations stem from not being able to assess individual patient data and were limited by a small cohort of patients and trials.

Additionally, the authors said that a longer follow-up period would have better evaluated mortality rates due to the fact that mortality rates for CABG are usually higher and earlier. “With longer follow-up, CABG patients may have improved survival rate compared with PCI patients,” the authors wrote.

"Drug-eluting stents reduce the rate of target vesel revascularization compared with bare metal sents in ULMCA PCI and may be a safe alternative to CABG," Lee and colleagues concluded.