Coronary artery bypass grafting (CABG) and PCI demonstrated similar long-term outcomes in treating left main coronary artery stenosis, according to a systematic review and meta-analysis of 4,394 patients. However, PCI was associated with a 70 percent increased risk of repeat revascularization.
A team of German researchers led by Daniele Giacoppo, MD, published these findings in JAMA Cardiology. They concluded both approaches are valid but have different strengths.
“Patient preference should be taken into consideration regarding the risks of periprocedural complications of surgery and long-term repeat revascularization after PCI,” wrote Giacoppo and colleagues. “Patients with low surgical risk may benefit from CABG owing to more sustained effectiveness as evidenced by the reduced incidence of repeat revascularization. However, if a patient is not a good candidate for surgery or wishes to avoid the morbidity associated with surgical revascularization, PCI is a safe and effective alternative.”
Four randomized clinical trials were included in the analysis—three with follow-up periods of five years and one with a three-year follow-up.
Exactly half of the patients included in the analysis received each type of procedure. Patients were an average of 65.4 years old, and 76.7 percent were men.
In a composite measure of all-cause death, MI or stroke, there was no significant difference between the procedures at the longest available follow-up. Repeat vascularization occurred in 313 patients in the PCI group compared to 184 in the CABG group. Second-generation and first-generation drug-eluting stents (DESs) showed a similar risk of repeat vascularization.
“Considering the large amount of evidence supporting the superior antirestenotic properties of second-generation DESs compared with first-generation DESs, it might be speculated that the superiority of CABG in this respect is driven by protection against the need for further revascularization in lesions outside the treated segment,” wrote Giacoppo et al. “In the EXCEL and NOBLE trials, a several-fold increased risk of revascularization outside the target lesion was observed with PCI compared with CABG.”
The authors noted the variance of follow-up times in the included trials may have limited the precision of their review. Also, all of the trials were designed to prove non-inferiority—sometimes containing large margins for comparison—which could limit the power in detecting differences in safety outcomes.