Surgical and percutaneous coronary revascularization in patients with multivessel or left main disease; what happens beyond five years? A systematic review and study level meta-analysis of randomized trials

Abstract

Meta-analysis exploring outcomes beyond 5-years of trials comparing coronary artery bypass graft (CABG) with percutaneous coronary intervention (PCI) utilizing drug-eluting stents in patients with coronary artery disease (CAD), are missing. We conducted a meta-analysis to compare very long-term outcomes, between the two interventions. Using electronic databases, we retrieved 4 trials, between January, 2010 and January, 2023. The primary endpoint was all-cause mortality. Kaplan-Meier curves of endpoint was reconstructed. Comparisons were made by Cox-linear regression frailty model and by landmark analysis. A flexible parametric model for survival analysis was used to obtain the time-dependent hazard-ratio. A random-effect method was applied. 5180 patients were included and randomized to CABG (n=2586) or PCI with DES (n=2594). During 10-year follow-up, PCI showed an overall higher incidence of all-cause mortality [hazard ratio (HR) 1.19; 95% confidence interval (CI), 1.104-1.32; p=0.008)]. At landmark analysis, PCI showed higher risk of the endpoint within 5-years (HR 1.2; 95% CI, 1.06-1.53; p=0.008) while no difference was found at 5-10-year period (HR,1.03; 95%CI, 0.84-1.26; p=0.76). The time-varying HR analysis of PCI versus CABG was consistent with the results of the landmark analysis. There was no long-term difference between the two interventions for myocardial infarction (MI) (OR,1.42; 95%CI, 0.92-2.18; p=0.11), composite of all-cause mortality, stroke or MI (OR,1.07; 95%CI, 0.84-1.36; p=0.57), stroke (OR,0.97; 95%CI, 0.59-1.59; p=0.91) and cardiovascular death (OR,1.02; 95%CI, 0.75-1.40; p=0.90), while PCI was associated with an increased risk for repeat revascularization (OR,2.11; 95%CI, 1.58-2.81; p<0.001) and major adverse cardiac and cerebrovascular events (OR,1.41; 95%CI, 1.13-1.75; p<0.0001). In conclusion, in patients with CAD, there was a significantly overall higher incidence of all-cause mortality after PCI compared to CABG beyond 5-year follow-up. Specifically, CABG is still favorable beyond 5 years and maintains its gold standard role for the CAD treatment; PCI has an evident higher mortality during the first 5 years and a comparable outcome beyond 5 years.