Minimally invasive surgical approaches to left main and left anterior descending coronary artery revascularization are superior compared to first- and second-generation drug-eluting stents: a network meta-analysis

Abstract

OBJECTIVES There are a number of minimally invasive approaches to revascularization of coronary artery disease that involve the left main or proximal left anterior descending artery; however, studies to date provide mixed results. METHODS A Bayesian network meta-analysis was performed to compare early and late postoperative outcomes between percutaneous coronary intervention with first- and second-generation drug-eluting stents (DESs), off-pump coronary artery bypass and minimally invasive direct coronary artery bypass (MIDCAB) in patients with involvement of left main or left anterior descending disease. RESULTS A total of 37 studies with 31 728 patients were included in the analysis. There were no significant differences in early mortality rates, strokes or myocardial infarctions (MIs). The long-term all-cause mortality rate was equivalent between the groups. Patients who had off-pump coronary artery bypass had fewer late MI compared with those who had first-generation DES (DES1) [odds ratio (OR) 0.38, 95% confidence interval (CI) 0.20–0.72] and MIDCAB (OR 0.41, 95% CI 0.17–0.97) and reduced late target vessel revascularization compared with DES1 (OR 0.17, 95% CI 0.09–0.32) and second-generation DES (DES2) (OR 0.32, 95% CI 0.14–0.72). The rate of late major adverse cardiac events was lower with off-pump coronary artery bypass compared with that with DES1 (OR 0.33, 95% CI 0.26–0.43) and DES2 (OR 0.62, 95% CI 0.45–0.90). The rate of late major adverse cardiac events with MIDCAB was lower than that with DES1 (OR 0.43, 95% CI 0.31–0.62) as was that with DES2 compared with DES1 (OR 0.53, 95% CI 0.39–0.70). CONCLUSIONS Surgical approaches to left main or proximal left anterior descending disease remain superior to first- or second-generation DES in terms of long-term freedom from MI and target vessel revascularization as well as improved overall long-term survival. Conflicting rates of late MI and target vessel revascularization in patients who underwent MIDCAB suggest disease in alternate vessels that may best be approached via hybrid techniques.

Very Long-term Outcome of Minimally Invasive Direct Coronary Artery Bypass

“…However, the revascularization rate at follow-up is more frequent after PCI than after CABG, even in patients with low or intermediate anatomical complexity [3]. In a recent meta-analysis, Indja B. et al [26] confirmed that MIDCAB for LAD remains superior to first-or second-generation PCI with drug eluting stent in term of long-term freedom from myocardial infarction and target vessel revascularization as well as of improved overall long-term survival.…”

Robotic coronary revascularization in Europe, state of art and future of EACTS-endorsed Robotic Cardiothoracic Surgery Taskforce

“…Furthermore, integrated PCIs provide the patient with the least invasive HCR option, achieving complete revascularization of all diseased coronary arteries. The use of the second-generation DES is of paramount importance in the treatment of non-LAD coronary pathology and provides a valuable alternative to surgical revascularization of non-LAD targets using a venous graft, the latter being notorious for future atherosclerotic degeneration resulting in high short-and long-term failure rates [5][6][7].…”

Cardiac Surgery 2020 Reviewed

“…A metaanalysis comparing MIDCAB to classic off-pump techniques and drug-eluting stents found no difference between the two surgical techniques and again demonstrated best outcomes with CABG. 31 The main findings of 2020 publications on surgical treatment for CAD are as follows:…”