Propensity Analysis of Long-Term Survival After Surgical or Percutaneous Revascularization in Patients With Multivessel Coronary Artery Disease and High-Risk Features

Abstract

Background-Although most randomized clinical trials have suggested that long-term survival rates after percutaneous coronary intervention (PCI) or surgical multivessel coronary revascularization (CABG) are equivalent, some post hoc analyses in high-risk groups and adjustment for severity of coronary disease have suggested higher mortality after PCI. Methods and Results-We studied 6033 consecutive patients who underwent revascularization in the late 1990s. PCI was performed in 872 patients; 5161 underwent CABG. Half the patients had significant left ventricular dysfunction or diabetes. Propensity analysis to predict the probability of undergoing PCI according to 22 variables and their interactions was used. The C-statistic for this model was 0.90, indicating excellent discrimination between treatments. There were 931 deaths during 5 years of follow-up. The 1-and 5-year unadjusted mortality rates were 5% and 16% for PCI and 4% and 14% for CABG (unadjusted hazard ratio, 1.13; 95% CI, 1.0 to 1.4; Pϭ0.07). PCI was associated with an increased risk of death (propensity-adjusted hazard ratio, 2.3; 95% CI, 1.9 to 2.9; PϽ0.0001). This difference was observed across all categories of propensity for PCI and in patients with diabetes or left ventricular dysfunction. Other independent predictors of mortality (PՅ0.01 for all) were renal dysfunction, age, diabetes mellitus, chronic lung disease, peripheral vascular disease, left main trunk stenosis, and extent of coronary disease (Duke angiographic score). Conclusions-In patients with multivessel coronary artery disease and many high-risk characteristics, CABG was associated with better survival than PCI after adjustment for risk profile.

Guidelines on myocardial revascularization

“…If PCI of the native vessel fails, angioplasty of the stenosed SVG remains an option. In chronically occluded SVG the success rates are considerably lower with even higher complication and restenosis rates than in non-occluded SVG [32].…”

“…Repeat revascularization in patients with graft failure is indicated in the presence of severe symptoms despite anti-anginal medication, and in patients with mild or no symptoms depending on risk stratification by non-invasive testing [32,164].…”

“…In a propensity analysis of long-term survival after redo CABG or PCI in patients with MVD and high-risk features, short-term outcome after either technique was very favourable, with nearly identical survival at 1 and 5 years [32]. In the AWESOME RCT and registry, overall in-hospital mortality was higher with CABG than with PCI [167,168].…”

“…CABG is preferred for patients with more diseased or occluded grafts, reduced systolic LV function, more total occlusion of native arteries, as well as absence of a patent arterial graft [32]. The ITA is the conduit of choice for revascularization during redo CABG [169].…”

Comparison of Off-pump Coronary Artery Bypass Grafting With Percutaneous Coronary Intervention Versus Drug-Eluting Stents for Three-Vessel Coronary Artery Disease

“…Several observational studies comparing the results of PCI and CABG showed better clinical outcome in the CABG patients [7][8][9], who had better survival and less need for reintervention in multivessel diseases compared with PCI patients. Also, in large series of clinical randomized trials, the CABG groups showed a lower incidence of repeat revascularization [4,5].…”