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DOI: 10.1055/s-0041-1735591
The Current State of Coronary Revascularization: Percutaneous Coronary Intervention versus Coronary Artery Bypass Graft Surgery
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Abstract
The question of percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) surgery remains among the most important questions in the treatment of coronary artery disease. The leading North American and European societies largely agree on the current guidelines for the revascularization of unprotected left-main disease (ULMD) and multivessel disease (MVD) which are largely supported by the outcomes of several large randomized trials including SYNTAX, PRECOMBAT, NOBLE, and EXCEL. While these trials are of the highest quality, currently available, they suffer several limitations, including the use of bare metal and/or first-generation drug-eluting stents in early trials and lack of updated surgical outcomes data. The objective of this review is to briefly discuss these key early trials, as well as explore contemporary studies, to provide insight on the current state of coronary revascularization. Evidence suggests that in ULMD and MVD, there are similar mortality rates for CABG and PCI but PCI is associated with fewer “early” strokes, whereas CABG is associated with fewer “late” strokes, myocardial infarctions, and lower need for repeat revascularization. Additionally, studies suggest that CABG remains superior to PCI in patients with intermediate/high SYNTAX scores and in MVD with concomitant proximal left anterior descending (pLAD) artery stenosis. Despite the preceding research and its basis for our current guidelines, there remains significant variation in care that has yet to be quantified. Emerging studies evaluating second-generation drug-eluting stents, specific lesion anatomy, and minimally invasive and hybrid approaches to CABG may lend itself to more individualized patient care.
Keywords
cardiology - coronary artery disease - coronary artery bypass graft surgery - percutaneous coronary interventionPublication History
Article published online:
10 November 2021
© 2021. International College of Angiology. This article is published by Thieme.
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References
- 1 Virani SS, Alonso A, Aparicio HJ. et al; American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics-2021 update: a report from the american heart association. Circulation 2021; 143 (08) e254-e743
- 2 De Bruyne B, Pijls NHJ, Kalesan B. et al; FAME 2 Trial Investigators. Fractional flow reserve-guided PCI versus medical therapy in stable coronary disease. N Engl J Med 2012; 367 (11) 991-1001
- 3 Chamberlain DA, Fox KA, Henderson RA, Julian DG, Parker DJ, Pocock SJ. Coronary angioplasty versus medical therapy for angina: the second Randomised Intervention Treatment of Angina (RITA-2) trial. RITA-2 trial participants. Lancet 1997; 350 (9076): 461-468
- 4 TIME Investigators. Trial of invasive versus medical therapy in elderly patients with chronic symptomatic coronary-artery disease (TIME): a randomised trial. Lancet 2001; 358 (9286): 951-957
- 5 O'Connor CM, Velazquez EJ, Gardner LH. et al. Comparison of coronary artery bypass grafting versus medical therapy on long-term outcome in patients with ischemic cardiomyopathy (a 25-year experience from the Duke Cardiovascular Disease Databank). Am J Cardiol 2002; 90 (02) 101-107
- 6 Maron DJ, Hochman JS, Reynolds HR. et al; ISCHEMIA Research Group. Initial invasive or conservative strategy for stable coronary disease. N Engl J Med 2020; 382 (15) 1395-1407
- 7 Glazier JJ, Ramos-Parra B, Kaki A. Therapeutic options for left main, left main equivalent, and three-vessel disease. Int J Angiol 2021; 30 (01) 76-82
- 8 Bangalore S, Kumar S, Fusaro M. et al. Short- and long-term outcomes with drug-eluting and bare-metal coronary stents: a mixed-treatment comparison analysis of 117 762 patient-years of follow-up from randomized trials. Circulation 2012; 125 (23) 2873-2891
- 9 Sarno G, Lagerqvist B, Nilsson J. et al. Stent thrombosis in new-generation drug-eluting stents in patients with STEMI undergoing primary PCI: a report from SCAAR. J Am Coll Cardiol 2014; 64 (01) 16-24
- 10 Bangalore S, Toklu B, Amoroso N. et al. Bare metal stents, durable polymer drug eluting stents, and biodegradable polymer drug eluting stents for coronary artery disease: mixed treatment comparison meta-analysis. BMJ 2013; 347: f6625
- 11 Darmoch F, Alraies MC, Al-Khadra Y, Moussa Pacha H, Pinto DS, Osborn EA. Intravascular ultrasound imaging-guided versus coronary angiography-guided percutaneous coronary intervention: a systematic review and meta-analysis. J Am Heart Assoc 2020; 9 (05) e013678
- 12 Hess CN, Lopes RD, Gibson CM. et al. Saphenous vein graft failure after coronary artery bypass surgery: insights from PREVENT IV. Circulation 2014; 130 (17) 1445-1451
- 13 Gaudino M, Benedetto U, Fremes S. et al; RADIAL Investigators. Radial-artery or saphenous-vein grafts in coronary-artery bypass surgery. N Engl J Med 2018; 378 (22) 2069-2077
- 14 Taggart DP, Benedetto U, Gerry S. et al; Arterial Revascularization Trial Investigators. Bilateral versus single internal-thoracic-artery grafts at 10 years. N Engl J Med 2019; 380 (05) 437-446
- 15 Buszman PE, Kiesz SR, Bochenek A. et al. Acute and late outcomes of unprotected left main stenting in comparison with surgical revascularization. J Am Coll Cardiol 2008; 51 (05) 538-545
- 16 Buszman PE, Buszman PP, Banasiewicz-Szkróbka I. et al. Left main stenting in comparison with surgical revascularization: 10-year outcomes of the (Left main coronary artery stenting) LE MANS trial. JACC Cardiovasc Interv 2016; 9 (04) 318-327
- 17 Seung KB, Park D-W, Kim Y-H. et al. Stents versus coronary-artery bypass grafting for left main coronary artery disease. N Engl J Med 2008; 358 (17) 1781-1792
- 18 Park D-W, Ahn J-M, Yun S-C. et al. 10-year outcomes of stents versus coronary artery bypass grafting for left main coronary artery disease. J Am Coll Cardiol 2018; 72 (23 Pt A): 2813-2822
- 19 Serruys PW, Morice M-C, Kappetein AP. et al; SYNTAX Investigators. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med 2009; 360 (10) 961-972
- 20 Mohr FW, Morice M-C, Kappetein AP. et al. Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial. Lancet 2013; 381 (9867): 629-638
- 21 Thuijs DJFM, Kappetein AP, Serruys PW. et al; SYNTAX Extended Survival Investigators. Percutaneous coronary intervention versus coronary artery bypass grafting in patients with three-vessel or left main coronary artery disease: 10-year follow-up of the multicentre randomised controlled SYNTAX trial. Lancet 2019; 394 (10206): 1325-1334
- 22 Park S-J, Kim Y-H, Park D-W. et al. Randomized trial of stents versus bypass surgery for left main coronary artery disease. N Engl J Med 2011; 364 (18) 1718-1727
- 23 Ahn J-M, Roh J-H, Kim Y-H. et al. Randomized trial of stents versus bypass surgery for left main coronary artery disease: 5-year outcomes of the PRECOMBAT study. J Am Coll Cardiol 2015; 65 (20) 2198-2206
- 24 Boudriot E, Thiele H, Walther T. et al. Randomized comparison of percutaneous coronary intervention with sirolimus-eluting stents versus coronary artery bypass grafting in unprotected left main stem stenosis. J Am Coll Cardiol 2011; 57 (05) 538-545
- 25 Mäkikallio T, Holm NR, Lindsay M. et al; NOBLE study investigators. Percutaneous coronary angioplasty versus coronary artery bypass grafting in treatment of unprotected left main stenosis (NOBLE): a prospective, randomised, open-label, non-inferiority trial. Lancet 2016; 388 (10061): 2743-2752
- 26 Holm NR, Mäkikallio T, Lindsay MM. et al; NOBLE investigators. Percutaneous coronary angioplasty versus coronary artery bypass grafting in the treatment of unprotected left main stenosis: updated 5-year outcomes from the randomised, non-inferiority NOBLE trial. Lancet 2020; 395 (10219): 191-199
- 27 Stone GW, Kappetein AP, Sabik JF. et al; EXCEL Trial Investigators. Five-year outcomes after pci or cabg for left main coronary disease. N Engl J Med 2019; 381 (19) 1820-1830
- 28 Stone GW, Sabik JF, Serruys PW. et al; EXCEL Trial Investigators. Everolimus-eluting stents or bypass surgery for left main coronary artery disease. N Engl J Med 2016; 375 (23) 2223-2235
- 29 Giacoppo D, Colleran R, Cassese S. et al. Percutaneous coronary intervention vs coronary artery bypass grafting in patients with left main coronary artery stenosis: a systematic review and meta-analysis. JAMA Cardiol 2017; 2 (10) 1079-1088
- 30 Palmerini T, Serruys P, Kappetein AP. et al. Clinical outcomes with percutaneous coronary revascularization vs coronary artery bypass grafting surgery in patients with unprotected left main coronary artery disease: a meta-analysis of 6 randomized trials and 4,686 patients. Am Heart J 2017; 190: 54-63
- 31 Ahmad Y, Howard JP, Arnold AD. et al. Drug-eluting stents versus bypass surgery for left main disease: an updated meta-analysis of randomized controlled trials with long-term follow-up. Am J Cardiol 2020; 132: 168-172
- 32 Al-Abcha A, Saleh Y, Mujer M, Herzallah K, Abela GS. Long-term outcomes of left main coronary artery disease treated with drug-eluting stents vs coronary artery bypass grafting: a meta-analysis and systematic review. Cardiovasc Revasc Med 2021; 23: 14-19
- 33 Ullah W, Sattar Y, Ullah I. et al. Percutaneous intervention or bypass graft for left main coronary artery disease? A systematic review and meta-analysis. J Interv Cardiol 2020; 2020: 4081642
- 34 Hyun J, Kim JH, Jeong Y. et al; MAIN-COMPARE Registry. Long-term outcomes after pci or cabg for left main coronary artery disease according to lesion location. JACC Cardiovasc Interv 2020; 13 (24) 2825-2836
- 35 Ram E, Goldenberg I, Kassif Y. et al. Real-life characteristics and outcomes of patients who undergo percutaneous coronary intervention versus coronary artery bypass grafting for left main coronary artery disease: data from the prospective Multi-vessel Coronary Artery Disease (MULTICAD) Israeli Registry. Eur J Cardiothorac Surg 2018; 54 (04) 717-723
- 36 Ram E, Goldenberg I, Sternik L. et al. Real-world referral pattern and outcomes of diabetic patients who undergo revascularization: data from the prospective Multi-vessel Coronary Artery Disease (MULTICAD) Israeli Registry†. Eur J Cardiothorac Surg 2019; 56 (02) 328-334
- 37 Valle JA, Tamez H, Abbott JD. et al. Contemporary use and trends in unprotected left main coronary artery percutaneous coronary intervention in the United States: an analysis of the national cardiovascular data registry research to practice initiative. JAMA Cardiol 2019; 4 (02) 100-109
- 38 Ko W, Tranbaugh R, Marmur JD, Supino PG, Borer JS. Myocardial revascularization in New York State: variations in the pci-to-cabg ratio and their implications. J Am Heart Assoc 2012; 1 (02) e001446
- 39 Chandrasekharan DP, Taggart DP. Informed consent for interventions in stable coronary artery disease: problems, etiologies, and solutions. Eur J Cardiothorac Surg 2011; 39 (06) 912-917
- 40 Babb JD, Schmidt RG, Berard TM, Field JM. Clinical features of left main equivalent coronary disease. Am J Cardiol 1980; 45 (02) 222-226
- 41 Califf RM, Conley MJ, Behar VS. et al. “Left main equivalent” coronary artery disease: its clinical presentation and prognostic significance with nonsurgical therapy. Am J Cardiol 1984; 53 (11) 1489-1495
- 42 Caracciolo EA, Davis KB, Sopko G. et al. Comparison of surgical and medical group survival in patients with left main equivalent coronary artery disease. Long-term CASS experience. Circulation 1995; 91 (09) 2335-2344
- 43 Eagle KA, Guyton RA, Davidoff R. et al. ACC/AHA guidelines for coronary artery bypass graft surgery: executive summary and recommendations: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to revise the 1991 guidelines for coronary artery bypass graft surgery). Circulation 1999; 100 (13) 1464-1480
- 44 Patel MR, Calhoon JH, Dehmer GJ. et al. ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2017 appropriate use criteria for coronary revascularization in patients with stable ischemic heart disease: a report of the American College of Cardiology appropriate use criteria task force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society of Thoracic Surgeons. J Am Coll Cardiol 2017; 69 (17) 2212-2241
- 45 Neumann F-J, Sousa-Uva M, Ahlsson A. et al; ESC Scientific Document Group. 2018 ESC/EACTS guidelines on myocardial revascularization. Eur Heart J 2019; 40 (02) 87-165
- 46 Garg S, Sarno G, Gutiérrez-Chico J-L, Garcia-Garcia HM, Gomez-Lara J, Serruys PW. ARTS-II investigators. Five-year outcomes of percutaneous coronary intervention compared to bypass surgery in patients with multivessel disease involving the proximal left anterior descending artery: an ARTS-II sub-study. EuroIntervention 2011; 6 (09) 1060-1067
- 47 Cavalcante R, Sotomi Y, Zeng Y. et al. Coronary bypass surgery versus stenting in multivessel disease involving the proximal left anterior descending coronary artery. Heart 2017; 103 (06) 428-433
- 48 Weintraub WS, Grau-Sepulveda MV, Weiss JM. et al. Comparative effectiveness of revascularization strategies. N Engl J Med 2012; 366 (16) 1467-1476
- 49 Park S-J, Ahn J-M, Kim Y-H. et al; BEST Trial Investigators. Trial of everolimus-eluting stents or bypass surgery for coronary disease. N Engl J Med 2015; 372 (13) 1204-1212
- 50 Watanabe H, Shiomi H, Morimoto T. et al; CREDO-Kyoto PCI/CABG registry/cohort-2 investigators. Percutaneous coronary intervention versus coronary arterial bypass grafting in patients with multi-vessel coronary revascularization (from the CREDO-Kyoto PCI/CABG registry/cohort-2). Catheter Cardiovasc Interv 2020; 96 (01) 42-51
- 51 Fanari Z, Weiss SA, Zhang W, Sonnad SS, Weintraub WS. Short, intermediate and long term outcomes of CABG vs. PCI with des in patients with multivessel coronary artery disease. Meta-analysis of six randomized controlled trials. Eur J Cardiovasc Med 2014; 3 (01) 382-389
- 52 Papadopoulos K, Lekakis I, Nicolaides E. Outcomes of coronary artery bypass grafting versus percutaneous coronary intervention with second-generation drug-eluting stents for patients with multivessel and unprotected left main coronary artery disease. SAGE Open Med 2017; 5: 2050312116687707
- 53 Bangalore S, Guo Y, Samadashvili Z, Blecker S, Xu J, Hannan EL. Everolimus-eluting stents or bypass surgery for multivessel coronary disease. N Engl J Med 2015; 372 (13) 1213-1222
- 54 Chen X, Zhang X, Yan Y. et al. Second generation drug-eluting stent implantation versus coronary artery bypass grafting in the treatment of young patients with left main and/or multivessel coronary disease. J Interv Cardiol 2020; 2020: 6736704
- 55 Edelman JJ, Yan TD, Padang R, Bannon PG, Vallely MP. Off-pump coronary artery bypass surgery versus percutaneous coronary intervention: a meta-analysis of randomized and nonrandomized studies. Ann Thorac Surg 2010; 90 (04) 1384-1390
- 56 Fan M-K, Su Y-M, Cai X-X. et al. Clinical outcomes of revascularization strategies for patients with MVD/LMCA disease: a systematic review and network meta-analysis. Medicine (Baltimore) 2015; 94 (42) e1745
- 57 Rosenblum JM, Harskamp RE, Hoedemaker N. et al. Hybrid coronary revascularization versus coronary artery bypass surgery with bilateral or single internal mammary artery grafts. J Thorac Cardiovasc Surg 2016; 151 (04) 1081-1089
- 58 Su C-S, Shen C-H, Chang K-H. et al. Clinical outcomes of patients with multivessel coronary artery disease treated with robot-assisted coronary artery bypass graft surgery versus one-stage percutaneous coronary intervention using drug-eluting stents. Medicine (Baltimore) 2019; 98 (38) e17202
- 59 Kapoor JR, Gienger AL, Ardehali R. et al. Isolated disease of the proximal left anterior descending artery comparing the effectiveness of percutaneous coronary interventions and coronary artery bypass surgery. JACC Cardiovasc Interv 2008; 1 (05) 483-491
- 60 Kinnaird T, Kwok CS, Narain A. et al. Meta-analysis of percutaneous coronary intervention with drug-eluting stent versus coronary artery bypass grafting for isolated proximal left anterior descending coronary disease. Am J Cardiol 2016; 118 (08) 1171-1177
- 61 Matsoukis IL, Karanasos A, Patsa C. et al. Long-term clinical outcomes of coronary artery bypass graft surgery compared to those of percutaneous coronary intervention with second generation drug eluting stents in patients with stable angina and an isolated lesion in the proximal left anterior descending artery. Catheter Cardiovasc Interv 2020; DOI: 10.1002/ccd.29247.
- 62 Thiele H, Neumann-Schniedewind P, Jacobs S. et al. Randomized comparison of minimally invasive direct coronary artery bypass surgery versus sirolimus-eluting stenting in isolated proximal left anterior descending coronary artery stenosis. J Am Coll Cardiol 2009; 53 (25) 2324-2331
- 63 Blazek S, Rossbach C, Borger MA. et al. Comparison of sirolimus-eluting stenting with minimally invasive bypass surgery for stenosis of the left anterior descending coronary artery: 7-year follow-up of a randomized trial. JACC Cardiovasc Interv 2015; 8 (1 pt A): 30-38
- 64 Harskamp RE, Williams JB, Halkos ME. et al. Meta-analysis of minimally invasive coronary artery bypass versus drug-eluting stents for isolated left anterior descending coronary artery disease. J Thorac Cardiovasc Surg 2014; 148 (05) 1837-1842
- 65 Hannan EL, Zhong Y, Cozzens K. et al. Revascularization for isolated proximal left anterior descending artery disease. Ann Thorac Surg 2021; 112 (02) 555-562
- 66 Indja B, Woldendorp K, Black D, Bannon PG, Wilson MK, Vallely MP. Minimally invasive surgical approaches to left main and left anterior descending coronary artery revascularization are superior compared to first- and second-generation drug-eluting stents: a network meta-analysis. Eur J Cardiothorac Surg 2020; 57 (01) 18-27
- 67 Frye RL, August P, Brooks MM. et al; BARI 2D Study Group. A randomized trial of therapies for type 2 diabetes and coronary artery disease. N Engl J Med 2009; 360 (24) 2503-2515
- 68 Farkouh ME, Domanski M, Sleeper LA. et al; FREEDOM Trial Investigators. Strategies for multivessel revascularization in patients with diabetes. N Engl J Med 2012; 367 (25) 2375-2384
- 69 Ariyaratne TV, Ademi Z, Yap C-H. et al. Prolonged effectiveness of coronary artery bypass surgery versus drug-eluting stents in diabetics with multi-vessel disease: an updated systematic review and meta-analysis. Int J Cardiol 2014; 176 (02) 346-353
- 70 Giustino G, Mehran R, Serruys PW. et al. Left main revascularization with pci or cabg in patients with chronic kidney disease: excel trial. J Am Coll Cardiol 2018; 72 (07) 754-765
- 71 Chan W, Ivanov J, Ko D. et al. Clinical outcomes of treatment by percutaneous coronary intervention versus coronary artery bypass graft surgery in patients with chronic kidney disease undergoing index revascularization in Ontario. Circ Cardiovasc Interv 2015; 8 (01) e001973
- 72 Šerpytis R, Puodžiukaitė L, Petrauskas S. et al. Outcomes of a percutaneous coronary intervention versus coronary artery bypass grafting in octogenarians. Acta Med Litu 2018; 25 (03) 132-139
- 73 Nicolini F, Contini GA, Fortuna D. et al. Coronary artery surgery versus percutaneous coronary intervention in octogenarians: long-term results. Ann Thorac Surg 2015; 99 (02) 567-574
- 74 Zhang Q, Zhao X-H, Gu H-F, Xu Z-R, Yang Y-M. Clinical outcomes of coronary artery bypass grafting vs percutaneous coronary intervention in octogenarians with coronary artery disease. Can J Cardiol 2016; 32 (09) 1166.e21-1166.e28