Percutaneous Coronary Intervention versus Coronary-Artery Bypass Grafting for Severe Coronary Artery Disease

Serruys, Patrick W.; Morice, Marie‐Claude; Kappetein, Arie Pieter; Colombo, Antonio; Holmes, David R.; Mack, Michael J.; Ståhle, Elisabeth; Feldman, Ted; Brand, Marcel van den; Bass, Eric J.; Dyck, Nic Van; Leadley, Katrin; Dawkins, Keith D.; Mohr, Friedrich W.; Scientif, Boston

doi:10.1056/nejmoa0804626

Cited by 3,814 publications

(2,754 citation statements)

References 38 publications

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“…However, this extraordinary reduction should be viewed in wider perspective; indeed, although not directly the objective of the current investigation, “no‐touch” OPCAB might offer the long‐term survival benefit of CABG over PCI,2, 35 together with similar or lower than PCI 30‐day stroke rates 36, 37. The discussion about potential shortcomings of CABG as compared to PCI was fueled after the first large industry‐funded trial3 found significantly higher rates of major adverse cardiac and cerebrovascular events in the PCI group (17.8% versus 12.4% for CABG; P =0.002), in large part because of an increased rate of repeat revascularization (13.5% versus 5.9%); however, at 12 months, strokes were 4‐fold more likely to occur with CABG (2.2% versus 0.6% with PCI; P =0.003). None of the following studies comparing PCI with OPCAB38, 39, 40, 41 were powered for stroke, and none reports the extent of “no‐touch” technique in the CABG group.…”

Section: Discussionmentioning

confidence: 94%

Cerebrovascular Events After No‐Touch Off‐Pump Coronary Artery Bypass Grafting, Conventional Side‐Clamp Off‐Pump Coronary Artery Bypass, and Proximal Anastomotic Devices: A Meta‐Analysis

Pawliszak

Kowalewski

Raffa

et al. 2016

JAHA

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BackgroundOff‐pump coronary artery bypass (OPCAB) has been shown to reduce the risk of neurologic complications as compared to coronary artery bypass grafting performed with cardiopulmonary bypass. Side‐clamping of the aorta while constructing proximal anastomoses, however, still carries substantial risk of cerebral embolization. We aimed to perform a comprehensive meta‐analysis of studies assessing 2 clampless techniques: aortic “no‐touch” and proximal anastomosis devices (PAD) for OPCAB.Methods and ResultsPubMed, CINAHL, CENTRAL, and Google Scholar databases were screened for randomized controlled trials and observational studies comparing “no‐touch” and/or PAD with side‐clamp OPCAB and reporting short‐term (≤30 days) outcomes: cerebrovascular accident and all‐cause mortality. A total of 18 studies (3 randomized controlled trials) enrolling 25 163 patients were included. Aortic “no‐touch” was associated with statistically lower risk of cerebrovascular accident as compared to side‐clamp OPCAB: risk ratio 95% CI: 0.41 (0.27–0.61); P<0.01; I2=0%. Event rates were 0.36% and 1.28% for “no‐touch” and side‐clamp OPCAB, respectively. No difference was seen between PAD and side‐clamp OPCAB: 0.71 (0.33–1.55); P=0.39; I2=39%. A trend towards increased 30‐day all‐cause mortality with PAD and no difference with “no‐touch” were observed when compared to side‐clamp OPCAB. In a subset analysis, “no‐touch” consistently reduced the risk of cerebrovascular accident regardless of patients’ baseline risk characteristics. A benefit with PAD was observed in low‐risk patients.ConclusionsAortic “no‐touch” technique was associated with nearly 60% lower risk of postoperative cerebrovascular events as compared to conventional side‐clamp OPCAB with effect consistent across patients at different risk.

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Section: Discussionmentioning

confidence: 94%

Cerebrovascular Events After No‐Touch Off‐Pump Coronary Artery Bypass Grafting, Conventional Side‐Clamp Off‐Pump Coronary Artery Bypass, and Proximal Anastomotic Devices: A Meta‐Analysis

Pawliszak

Kowalewski

Raffa

et al. 2016

JAHA

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“…Fractional flow reserve (FFR) is currently the standard for decision‐making regarding revascularization in the catheter laboratory and has become part of the clinical guidelines for the assessment of the physiological significance of epicardial coronary stenosis based on sound concepts and randomized clinical trials 8, 9, 10, 11. However, FFR evaluation is still underutilized; instead, coronary angiography is widely used as a gatekeeper for decision‐making of revascularization even in large clinical trials 2, 12. Subanalysis of the FAME (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation) trial has shown that angiography is inaccurate for assessing the functional significance of coronary stenosis when compared with FFR guidance, especially for intermediate stenosis 6.…”

Section: Introductionmentioning

confidence: 99%

Significance of Microvascular Function in Visual—Functional Mismatch Between Invasive Coronary Angiography and Fractional Flow Reserve

Yonetsu

Murai

Kanaji

et al. 2017

JAHA

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BackgroundDespite a moderate correlation between angiographical stenosis and physiological significance, the mechanism of discordance has not been fully elucidated, particularly regarding the significance of microvascular function. This study sought to clarify whether microvascular function affects visual‐functional mismatch between quantitative coronary angiography (QCA) and fractional flow reserve (FFR).Methods and ResultsWe assessed QCA, FFR, coronary flow reserve, and the index of microcirculatory resistance in 849 non‐left‐main coronary lesions with visually estimated intermediate stenoses from 532 patients. Clinical and lesion‐specific characteristics and physiological parameters associated with mismatch and reverse mismatch were studied. Coronary flow reserve and index of microcirculatory resistance showed a weak, but significant, correlation with FFR (R=0.306, P<0.001 and R=0.158, P<0.001, respectively). Four hundred twenty‐two lesions were visually nonsignificant (diameter stenosis assessed by QCA [QCA‐DS] ≤50%) and 427 lesions were visually significant (QCA‐DS >50%). Among visually nonsignificant lesions, FFR ≤0.80 (reverse mismatch) was observed in 129 lesions (30.6%). Among visually significant lesions, FFR >0.80 (mismatch) were observed in 179 lesions (41.9%). The significant predictors of reverse mismatch were male sex, nonculprit lesions of acute coronary syndrome, left anterior descending artery location, smaller QCA reference diameter, greater QCA‐DS, lower coronary flow reserve, and lower index of microcirculatory resistance. Mismatch was associated with right coronary artery location, greater QCA reference diameter, smaller QCA‐DS, lesion length, higher coronary flow reserve, and higher index of microcirculatory resistance.ConclusionsThere was a high prevalence of visual‐functional mismatches between QCA and FFR. The discrepancy was related to clinical characteristics, lesion‐specific factors, and microvascular resistance that was undistinguishable by coronary angiography, thus suggesting the importance of physiological lesion assessment.

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“…The primary aim of SYNTAX was to assess the optimal revascularization strategy for patients with 3‐vessel disease or left main trunk disease, by randomizing patients to PCI with paclitaxel‐eluting DES or CABG 58. This trial demonstrated a significantly higher occurrence of major adverse cardiovascular and cerebrovascular events among patients treated with PCI as compared to CABG 58.…”

Section: Lessons Learned From Complex Percutaneous Coronary Interventmentioning

confidence: 99%

Choice and Selection of Treatment Modalities for Cardiac Patients: An Interventional Cardiology Perspective

Agarwal

Tuzcu

Kapadia

2015

JAHA

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Percutaneous Coronary Intervention versus Coronary-Artery Bypass Grafting for Severe Coronary Artery Disease

Cited by 3,814 publications

References 38 publications

Cerebrovascular Events After No‐Touch Off‐Pump Coronary Artery Bypass Grafting, Conventional Side‐Clamp Off‐Pump Coronary Artery Bypass, and Proximal Anastomotic Devices: A Meta‐Analysis

Cerebrovascular Events After No‐Touch Off‐Pump Coronary Artery Bypass Grafting, Conventional Side‐Clamp Off‐Pump Coronary Artery Bypass, and Proximal Anastomotic Devices: A Meta‐Analysis

Significance of Microvascular Function in Visual—Functional Mismatch Between Invasive Coronary Angiography and Fractional Flow Reserve

Choice and Selection of Treatment Modalities for Cardiac Patients: An Interventional Cardiology Perspective

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