Coronary angioplasty in drug eluting stent era for the treatment of unprotected left main stenosis compared to coronary artery bypass grafting

Mäkikallio, Timo H.; Niemelä, Matti; Kervinen, Kari; Jokinen, Vesa; Laukkanen, Jari A.; Ylitalo, Ikari; Tulppo, Mikko P.; Juvonen, Jukka; Huikuri, Heikki V.

doi:10.1080/07853890701879790

Cited by 63 publications

(41 citation statements)

References 33 publications

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“…Second-generation drug-eluting stents have been shown to reduce TVR rates significantly in all lesions when compared with bare metal stents or first-generation drug-eluting stents. 32,33 Adherence to optimal medical therapy may influence the occurrence of post-CABG cerebrovascular events. Recent analyses of data from a health plan database revealed that CABG patients were less likely to be on statins or angiotensin converting enzyme inhibitors, which in turn puts them at higher risk of cardiovascular events.…”

Section: Discussionmentioning

confidence: 99%

Late Stroke: Comparison of Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Patients With Multivessel Disease and Unprotected Left Main Disease

Athappan

Chacko

Patvardhan

et al. 2014

Stroke

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Background and Purpose-Studies have suggested that the early excess risk of stroke in coronary artery bypass grafting (CABG) may be compensated for by a slow but progressive catch-up phenomenon in patients undergoing percutaneous coronary intervention (PCI). We therefore undertook this analysis to compare the temporal stroke risk between PCI and CABG in patients with unprotected left main stenosis and multivessel coronary artery disease. Methods-Studies of PCI versus CABG for unprotected left main stenosis and multivessel disease published between January 1994 (stent era) and July 2013 were identified using an electronic search and reviewed using meta-analytic techniques. Results-We selected 57 reports for the meta-analysis by applying the inclusion and exclusion criteria. The primary search terms used were CABG and PCI. For the Cochrane database the search terms were limited by the term clinical trial. Limiting the search parameters to the English language was applied subsequently. Citations were screened at the title and abstract level and retrieved as full reports if they were clinical studies, compared PCI with CABG, and provided information on the outcome of stroke. The full texts of all potential articles were reviewed in detail. The bibliography of retained studies was used to seek additional relevant studies. Inclusion CriteriaStudies were included if the following criteria applied: (1) comparative trials of CABG versus PCI with stent placement, (2) unprotected left main stenosis of >50% narrowing or multivessel disease, (3) a minimum of 30 patients, and (4) a minimum follow-up of 1 year. When 2 similar studies were reported from the same institution or author, the most recent publication was included in the analysis. Exclusion CriteriaStudies were excluded if any of the following criteria applied: (1) outcome of interest was not clearly reported or was impossible to extract or calculate from the published results, (2) <1-year follow-up, (3) included patients with ST-segment-elevation myocardial infarction, and (4) included patients with percutaneous transluminal coronary angioplasty without stents. Data ExtractionInformation collected included first author, year and journal of publication, study design, inclusion/exclusion criteria, definition of primary and secondary end points, number of subjects included, subjects undergoing PCI and CABG, percentage of drug-eluting stent used, study population demographics, number of diseased vessels, stenting technique, type of CABG (on pump versus off pump), left internal mammary artery graft used (single versus double), follow-up time period, rates of angiographic follow-up, antiplatelet regimen used, and primary and secondary outcomes. There was no disagreement between the 2 reviewers (G.A. and P.C.).

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Section: Discussionmentioning

confidence: 99%

Late Stroke: Comparison of Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Patients With Multivessel Disease and Unprotected Left Main Disease

Athappan

Chacko

Patvardhan

et al. 2014

Stroke

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“…A review of the 2011 PCI guideline and Data Supplements 3 and 4 12 revealed that 4 randomized trials [13][14][15][16] and 8 cohort studies [17][18][19][20][21][22][23][24] comprised the evidence for the new Class IIa recommendation for PCI to improve survival in patients with ULMCAD, whereas 7 older studies formed the knowledge base to show that CABG confers a survival advantage over MT in patients with ULMCAD. [2][3][4][5][6][7][8] The 19 studies used predefined enrollment criteria and were published in peer-reviewed journals.…”

Section: Methodsmentioning

confidence: 99%

“…Evidence for the second premise comes from 4 randomized trials [13][14][15][16] and 8 cohort studies, [17][18][19][20][21][22][23][24] all reported during the past 7 years.…”

Section: Clinical Perspective On P 2185mentioning

confidence: 99%

“…We assumed that the number of deaths in the CABG arm arose from a binomial distribution and that the log-odds of the study-specific CABG mortality rate had a noninformative normal prior distribution. For the 12 studies that directly compared CABG with PCI, [13][14][15][16][17][18][19][20][21][22][23][24] we assumed that the number of deaths in the PCI arm was also a binomial variable with the log-odds of the study-specific PCI mortality rate modeled as the rate for the CABG surgery arm plus a study-specific increment associated with the PCI arm. The study-specific effect attributed to PCI was assumed to arise from a normal distribution with unknown mean and unknown PCI-specific between-study variance.…”

Section: Bayesian Meta-analysesmentioning

confidence: 99%

“…[21][22][23][24] We first used a hierarchical bayesian model for the comparative effectiveness between PCI and CABG, imposed noninformative priors so that the posterior inference would be dominated by the likelihood of the data, and observed that the posterior median for the summary OR was 1.04 and the 95% bayesian credible interval (BCI) was 0.74 to 1.39. Because the interval included 1, the results showed no significant difference between the 2 treatments for 1-year mortality.…”

Section: Bayesian Cross-design Analysis Of Studies Comparing Pci Withmentioning

confidence: 99%

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Bayesian Methods Affirm the Use of Percutaneous Coronary Intervention to Improve Survival in Patients With Unprotected Left Main Coronary Artery Disease

Bittl

Jacobs

et al. 2013

Circulation

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Background-Several randomized clinical trials support the use of coronary artery bypass grafting (CABG) for patients with unprotected left main coronary artery disease. Studies suggesting the equivalence of percutaneous coronary intervention (PCI) with CABG for this indication indirectly support the 2011 American College of Cardiology Foundation/American Heart Association Class IIa recommendation for PCI to improve survival in patients with unprotected left main coronary artery disease. We tested whether bayesian approaches uphold the new recommendation. Methods and Results-We performed a bayesian cross-design and network meta-analysis of 12 studies (4 randomized clinical trials and 8 observational studies) comparing CABG with PCI (n=4574 patients) and of 7 studies (2 randomized clinical trials and 5 observational studies) comparing CABG with medical therapy (n=3224 patients). The odds ratios of 1-year mortality after PCI compared with CABG using bayesian cross-design meta-analysis were not different among randomized clinical trials (odds ratio, 0.99; 95% bayesian credible interval, 0.67-1.43), matched cohort studies (odds ratio, 1.10; 95% bayesian credible interval, 0.76-1.73), and other types of cohort studies (odds ratio, 0.93; 95% bayesian credible interval, 0.58-1.35). A network meta-analysis suggested that medical therapy is associated with higher 1-year mortality than the use of PCI for patients with unprotected left main coronary artery disease (odds ratio, 3.22; 95% bayesian credible interval, 1.96-5.30). Conclusions-Bayesian methods support the current guidelines, which were based on traditional statistical methods and have proposed that PCI, like CABG, improves survival for patients with unprotected left main coronary artery disease compared with medical therapy. An integrated approach using both direct and indirect evidence may yield new insights to enhance the translation of clinical trial data into practice.

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Percutaneous Coronary Intervention in Unprotected Left Main

Chieffo

Colombo

2016

Interventional Cardiology

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Coronary angioplasty in drug eluting stent era for the treatment of unprotected left main stenosis compared to coronary artery bypass grafting

Abstract: PCI with DES for selected LMCA disease patients results in short- and midterm outcomes comparable to results of CABG in general. PCI is a viable therapeutic option in selected patients with LMCA stenosis.

Cited by 63 publications

References 33 publications

Late Stroke: Comparison of Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Patients With Multivessel Disease and Unprotected Left Main Disease

Late Stroke: Comparison of Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Patients With Multivessel Disease and Unprotected Left Main Disease

Bayesian Methods Affirm the Use of Percutaneous Coronary Intervention to Improve Survival in Patients With Unprotected Left Main Coronary Artery Disease

Percutaneous Coronary Intervention in Unprotected Left Main

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