Long-term outcomes of coronary artery bypass grafting versus stent-PCI for unprotected left main disease: a meta-analysis

Abstract

BackgroundCoronary artery bypass graft (CABG) surgery has traditionally represented the standard of care for left main coronary artery (LMCA) disease. However, percutaneous coronary intervention with stent implantation (PCI) has more recently emerged as a valuable alternative. The long-time awaited results of the largest randomized trials on the long-term impact of PCI versus CABG in LMCA disease, the newly published NOBLE and EXCEL studies, revealed contrasting results. Thus, aim of the present meta-analysis was to review the most robust evidence from randomized comparisons of CABG versus PCI for revascularization of LMCA.MethodsRandomized studies comparing long-term clinical outcomes of CABG or Stent-PCI for the treatment of LMCA disease were searched for in PubMed, the Chochrane Library and Scopus electronic databases. A total of 5 randomized studies were selected, including 4499 patients.ResultsNo significant difference between CABG and PCI was found in the primary analysis on the composite endpoint of death, stroke and myocardial infarction (OR = 1·06 95% CI 0·80–1·40; p = 0·70). Similarly, no differences were observed between CABG and PCI for all-cause death (OR = 1·03 95% CI 0·81–1·32; p = 0·81). Although not statistically significant, a lower rate of stroke was registered in the PCI arm (OR = 0·86; p = 0·67), while a lower rate of myocardial infarction was found in the CABG arm (OR = 1·43; p = 0·17). On the contrary, a significantly higher rate of repeat revascularization was registered in the PCI arm (OR = 1·76 95% CI 1·45–2·13; p < 0·001).ConclusionsThe present meta-analysis, the most comprehensive and updated to date, including 5 randomized studies and 4499 patients, demonstrates no difference between Stent-PCI and CABG for the treatment of LMCA disease in the composite endpoint of death, stroke and myocardial infarction. Hence, a large part of patients with unprotected left main coronary artery disease can be managed equally well by means of both these revascularization strategies.Electronic supplementary materialThe online version of this article (doi:10.1186/s12872-017-0664-5) contains supplementary material, which is available to authorized users.

Climbing the hill of left main coronary artery revascularization: percutaneous coronary intervention or coronary artery bypass graft?

“…Our recent meta-analysis suggested additional benefit from the use of clinical variables to select the best revascularization strategy. In fact, diabetes was associated with a better performance of CABG over PCI on the long-term clinical success at meta-regression (12). In line with this concept, it was demonstrated that addition of clinical parameters to the mere anatomical evaluation makes risk stratification more effective (14).…”

“…Nevertheless, CABG seems to perform better in specific patients' categories, such as complex anatomical settings or females. On the contrary, PCI performs better in older patients and less diffuse coronary disease (12).…”

“…In fact, in our recent meta-analysis comparing PCI vs. CABG for the treatment of ULMCA disease, CABG was associated with a better outcome, in terms of the composite endpoint of death, MI, stroke or repeat revascularization on the longterm (>24 months) only in the subgroup of patients with a Syntax score over 33. We should notice that this difference was mainly driven by an excess of repeat revascularization rate in patients who had been randomized to PCI (12). To this regard, it should be noticed that the 10-year follow up of the LE MANS study revealed a late catch-up, with repeat revascularizations occurring later but almost reaching up in prevalence with PCI (13).…”

“…Further key elements in the decision-making process for treating ULMCA disease that are missing in the article by Mahmoud and colleagues but are well worth a mention are: (I) the known difference in terms of technical execution and clinical outcome for PCI between stenting of the LM ostium or trunk and the treatment of bifurcation or trifurcation lesions, that are associated with a higher rate of restenosis, while lesion location has no relevant influence on long-term results of CABG; (II) the angiographic definition of "significant" ULMCA disease remains challenging, whereas intracoronary evaluation techniques such as intracoronary imaging (IVUS/OCT) or iFR/FFR might be very helpful in this setting (15)(16)(17)(18); (III) PCI techniques to treat the stenosis of ULMCA are different and quite heterogeneous, and we know that implantation techniques have a significant impact on clinical results for PCI of a ULMCA (18); (IV) in our recent meta-regression analysis, older patients did better with PCI than CABG (12).…”

Complex coronary intervention outcomes: real world left main coronary artery angioplasty experience from a tertiary care center in South India

“…[10][11][12][13] In addition to the data from single studies, meta-analysis of multiple studies is a major contributor to the evidence of LMCA stenosis treatment. 11,14 India being among the most populated geographies in the world, the cases of LMCA stenosis are also proportionately high in numbers. Based upon this aspect, we decided to evaluate the data of LMCA angioplasty that were performed in our hospital, a tertiary care center in South India.…”