A meta-analysis of randomized control trials comparing minimally invasive direct coronary bypass grafting versus percutaneous coronary intervention for stenosis of the proximal left anterior descending artery

Abstract

Percutaneous intervention (PCI) and minimally invasive direct coronary bypass grafting (MIDCAB) are both well-accepted treatment options for isolated high-grade stenosis of proximal left anterior descending coronary artery. Small studies comparing the two modalities have yielded conflicting results. We performed a meta-analysis of randomized control trials to compare percutaneous intervention with minimally invasive coronary bypass grafting for isolated proximal left anterior descending artery stenosis. Five randomized trials with a total of 711 patients and average follow-up of 2.3 years were included in the analysis; 380 patients received stents and 331 underwent surgery. Only one trial used drug eluting stents. There were a small number of events overall in each trial. Difference between mortality was 12 events versus 15 between the PCI versus MIDCAB group. Similarly, the difference in myocardial infarction was 14 versus 10, and target vessel revascularization was 56 versus 19. The relative risk for stenting versus MIDCAB was 0.96 [(95% CI: 0.47, 1.99), p=0.92, I(2)=17.5%], for mortality and myocardial infarction, 0.77 [(95% CI: 0.30, 2.01), p=0.60, I(2)=10.4%] for mortality and 1.81 [(95% CI: 0.80, 4.06), p=0.15, I(2)=65.9%] for the composite end point of mortality, myocardial infarction and target vessel revascularization. Excluding the trial with drug eluting stents the relative risk for the composite outcome of mortality, myocardial infarction and target vessel revascularization was significantly higher for PCI [RR=2.27 (95% CI: 1.32, 3.90), p=0.003, I(2)=18.9%]. Overall mortality and myocardial infarction rates are similar for bare metal stents versus MIDCAB, but surgery was associated with significantly lower rates of repeat revascularization. The number of randomized patients and events were small. The effect of drug eluting stents might close the gap of repeat revascularization compared to MIDCAB for this disease.

2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention

“…In the 1970s and 1980s, 3 RCTs established the survival benefit of CABG compared with contemporaneous (although minimal by current standards) medical therapy without revascularization in certain subjects with stable angina: the Veter-ans Affairs Cooperative Study, 114 European Coronary Surgery Study, 55 and CASS (Coronary Artery Surgery Study). 115 Subsequently, a 1994 meta-analysis of 7 studies that randomized a total of 2649 patients to medical therapy or CABG 30 showed that CABG offered a survival advantage over medical therapy for patients with left main or 3-vessel CAD.…”

2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery

“…69,[72][73][74][75][76][77][78][79][80][81][82][83] A retrospective cohort study of 14 766 consecutive patients undergoing isolated CABG identified a mortality benefit (OR: 0.45) for off-pump CABG in patients with a predicted risk of mortality Ͼ2.5%, 82 but a subsequent randomized comparison of off-pump CABG to traditional on-pump CABG in 341 high-risk patients (a Euroscore Ͼ5) showed no difference in the composite endpoint of all-cause death, acute MI, stroke, or a required reintervention procedure. 78 An analysis of data from the New York State Cardiac Surgery Reporting system did not demonstrate a reduction in mortality rate with off-pump CABG in any patient subgroup, including the elderly (age Ͼ80 years) or those with cerebrovascular disease, azotemia, or an extensively calcified ascending aorta.…”

Randomized Comparison of Minimally Invasive Direct Coronary Artery Bypass Surgery Versus Sirolimus-Eluting Stenting in Isolated Proximal Left Anterior Descending Coronary Artery Stenosis

“…Established treatment options for isolated proximal LAD lesions are minimally invasive direct coronary artery bypass (MIDCAB) surgery with the left internal mammary artery (LIMA) as bypass graft and percutaneous coronary intervention (PCI) with bare-metal stents (3,4). Both treatment strategies effectively reduce symptoms (3).…”