Percutaneous intervention versus coronary artery bypass graft surgery in left main coronary artery stenosis: a systematic review and meta-analysis

Abstract

BackgroundThe optimal revascularization technique in patients with left main coronary artery disease (CAD) remains controversial. We aimed to compare the long-term performance of percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) surgery in treatment of left main CAD.MethodsPubMed, EMBASE, and the Cochrane Library were searched until November 16, 2016.ResultsSix randomized controlled trials and 22 matched observational studies including 22,487 patients and 90,167 patient-years of follow-up were included. PCI was associated with an overall higher risk for the major adverse cardiac and cerebrovascular events (hazard ratio (HR), 1.42; 95% confidence interval (CI), 1.14–1.77), mainly driven by higher rates of myocardial infarction (HR, 1.69; 95% CI, 1.22–2.34) and revascularization (HR, 2.80; 95% CI, 1.86–4.22). The overall risks for all-cause death (HR, 1.05; 95% CI, 0.93–1.20), cardiac death (HR, 1.05; 95% CI, 0.69–1.59), stroke (HR, 0.64; 95% CI, 0.33–1.24), and the composite safety endpoint of death, myocardial infarction, or stroke (HR, 1.06; 95% CI, 0.97–1.16) were similar between PCI and CABG. Stratified analysis based on stent types showed that the increased risk for myocardial infarction associated with PCI was only evident in patients with bare-metal stents or early-generation drug-eluting stents (DES), but not newer-generation DES. Stratified analyses based on study designs showed largely similar findings with the overall analyses, except for a significantly higher incidence of myocardial infarction in adjusted studies (HR, 2.01; 95% CI, 1.64–2.45) but a trend toward higher incidence in randomized trials (HR, 1.39; 95% CI, 0.85–2.27) associated with PCI.ConclusionsCompared with CABG, PCI with newer-generation DES might be a safe alternative revascularization strategy for treatment of left main CAD, but is associated with more repeat revascularization.Electronic supplementary materialThe online version of this article (doi:10.1186/s12916-017-0853-1) contains supplementary material, which is available to authorized users.

Clinical outcome comparison of percutaneous coronary intervention and bypass surgery in diabetic patients with coronary artery disease: a meta-analysis of randomized controlled trials and observational studies

“…Previous studies have compared the two revascularization strategies and found different results than those observed in the current study. Although no separate analysis of diabetic cohorts was performed, a meta-analysis by Zhang et al [35] suggested that PCI, with newer generation DES, might be a safe alternative revascularization strategy for left main CAD. However, it was noted that this method presented a higher risk of repeat revascularization.…”

Approaches to therapeutic angiogenesis for ischemic heart disease

“…Coronary atherosclerosis causes blockage of the coronary arteries, leading to myocardial ischemia, myocardial infarction (MI), and ischemic cardiomyopathy. Current medical interventions for IHD include pharmacologic therapy (antiplatelet drugs, β-blockers, or statins) for disease stabilization and reduction of acute events (e.g., myocardial infarction or sudden death) or immediate restoration of the blood supply via surgical treatment, such as coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI), two of the most common revascularization procedures performed worldwide [3,4]. However, a significant number of patients are clinically refractory to medical therapy and are ineligible to receive either PCI or CABG due to the patient's clinical condition or to technological limitations of currently available therapies [2,4,5].…”

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“…These drugs are used for condition stabilization and reduction of acute events. Alternatively, the blood supply can be restored immediately by surgical treatment [ 7 , 8 ]. However, the reperfusion paradoxically causes further myocardial contractile dysfunction and cardiomyocyte death, a phenomenon known as ischemia/reperfusion (I/R) injury.…”