Meta-Analysis Comparing Outcomes of Drug Eluting Stents Versus Single and Multiarterial Coronary Artery Bypass Grafting

Abstract

Relative benefits of coronary artery bypass (CABG) using single and multiple arterial grafting (SAG, MAG) and drug eluting stent (DES) in multivessel coronary disease remain uncertain. We compared SAG, MAG and DES in a pairwise and network meta-analysis. Randomized trials and adjusted observational studies comparing CABG versus DES were included (primary endpoint: long-term mortality; secondary endpoints: operative mortality, perioperative stroke and followup repeated revascularization [RR]). Studies with ≥1.7arterial grafts/patient were classified as MAG. Bayesian network meta-analyses (NMAs) and random-model pairwise meta-analyses were performed. 53,239 patients (8 randomized, 17 observational studies) were included (26,306 DES;26,933 CABG). In pairwise comparison (mean follow-up:5.42 years), CABG (MAG+SAG) was associated with lower long-term mortality (incident rate ratio[IRR]0.77, 95%CI 0.66-0.90), lower RR (IRR 0.37, 95%CI 0.27-0.51), increased perioperative stroke (odds ratio[OR]3.18, 95%CI 1.70-5.97) and similar operative mortality (OR 1.04, 95%CI 0.64-1.70) compared to DES. There was a non-significant trend toward lower long-term mortality for studies with higher mean number of arterial grafts. In NMA, compared to DES, MAG was associated with lower long-term mortality (IRR 0.72, 95%CrI 0.57-0.92) and late RR (IRR 0.32, 95%CrI 0.21-0.49), SAG was associated with lower long-term mortality and RR (IRR 0.80, 95%CrI 0.66-0.97 and IRR 0.42, 95%CrI 0.29-0.61 respectively). In conclusion, CABG was associated with reduced 5-year mortality and need for RR compared to DES. MAG was ranked as the best treatment for the primary and all secondary outcomes.

Saphenous vein harvesting: A touchy subject

“…13 The benefits of a second and even a third arterial graft (after the LITA-LAD) are increasingly recognized and multiarterial CABG seems superior to percutaneous coronary intervention for multivessel disease. [13][14][15] However, additional arterial grafts in the form of the radial artery and the RITA are not without drawbacks, including risks of spasm, hand ischemia, sternal wound infection, and compromised future dialysis access options in renal failure patients. The SVG will, therefore, continue to have a role in CABG, and efforts to optimize its outcomes may allow it to compete more successfully with other arterial options.…”

“…Current drug‐eluting stent patency rates rival those of the SVG 13 . The benefits of a second and even a third arterial graft (after the LITA‐LAD) are increasingly recognized and multiarterial CABG seems superior to percutaneous coronary intervention for multivessel disease 13–15 . However, additional arterial grafts in the form of the radial artery and the RITA are not without drawbacks, including risks of spasm, hand ischemia, sternal wound infection, and compromised future dialysis access options in renal failure patients.…”

Percutaneous Coronary Intervention with Stenting versus Coronary Artery Bypass Grafting in Stable Coronary Artery Disease

“…[41][42][43] While more data is needed before making definitive conclusions, CABG utilizing MAG may lead to stronger data supporting CABG over PCI. 44 The concept of complete revascularization (CR) has long been surgical dogma, although it has been variably defined across studies. Among CABG patients, CR is associated with improved outcomes when compared with incomplete revascularization.…”

Total arterial coronary artery bypass grafting in patients with preoperative anemia

“…Total arterial revascularization‐coronary artery bypass grafting (TAR‐CABG), beside the suggested benefits in terms of graft patency, 16–19 long‐term survival, and freedom from cardiac events, 20–28 has been previously associated to reduced blood products consumption when compared to revascularization using saphenous vein (SV)‐CABG) grafts 29,30 . In fact, SV harvesting may be a source of concealed bleeding frequently passing unnoticed and might explain this finding 29,31 …”