Transradial Coronary Intervention Versus Coronary Artery Bypass Grafting for Unprotected Left Main and/or Multivessel Disease in Patients With Acute Coronary Syndrome

Abstract

The overall safety and efficacy of transradial coronary intervention (TRI) versus coronary artery bypass grafting (CABG) for patients with unprotected left main (UPLM) disease and/or multivessel coronary disease (MVD) presenting with acute coronary syndrome (ACS) have not been established. Consecutive patients with ACS undergoing TRI with drug-eluting stent (n ¼ 1431) or CABG (n ¼ 651) for UPLM and/or MVD were included. A propensity-score matching was performed to adjust for differences in baseline characteristics between the 2 cohorts, yielding 524 pairs of matched patients. Median clinical follow-up was 32 months. After propensity-score adjustment, no significant difference was observed between the TRI and CABG groups in all-cause mortality (4.0% vs 5.2%; P ¼ .375). Transradial coronary intervention was favored by a significant increase in the incidence of stroke in the CABG group (0.4% vs 1.9%; P ¼ .020), whereas a significantly increased target vessel revascularization rate (16.8% vs 6.3%; P < .0001) observed in the TRI group favored CABG. Composite outcome (death/myocardial infarction/ stroke) was comparable between the TRI and the CABG groups (8.0% vs 11.5%; P ¼ .061). Clinical outcomes of TRI on UPLM and/or MVD for patients with ACS are comparable to CABG in composite safety outcomes with the advantage to TRI for avoiding a stroke.

Drug‐eluting stents versus coronary artery bypass grafting for left‐main coronary artery disease

“…Of 173 potentially relevant articles screened initially, we identified 5 RCTs and 17 observational studies with propensity‐score analysis of DES‐PCI versus CABG for LMCAD with ≥6‐month follow‐up enrolling a total of 12,387 patients (Tables and ). These included the NOBLE study , the EXCEL trial , the PRECOMBAT [Bypass Surgery Versus Angioplasty Using Sirolimus‐ Eluting Stent in Patients With Left Main Coronary Artery Disease] study , the SYNTAX [Synergy Between PCI With Taxus and Cardiac Surgery] trial , the DELTA [Drug‐Eluting Stent for Left Main Coronary Artery Disease] registry , the CUSTOMIZE [Appraise a CUSTOMIZEd strategy for left main revascularization] registry , the ASAN‐MAIN [ASAN medical center–left MAIN revascularization] registry , the MAIN‐COMPARE [Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary Angioplasty Versus Surgical Revascularization] registry , etc.…”

“…Drug‐eluting stents (DES) are suggested to be associated with favorable outcomes for mortality, myocardial infarction (MI), target‐vessel/lesion (TV/TL) repeat revascularization (RRV) (TV‐/TL‐RRV), and major adverse cardiac events as compared with bare‐metal stents (BMS) in PCI for LMCAD . Furthermore, a number of medium‐ to large‐size randomized controlled trials (RCTs) (the NOBLE [Nordic‐Baltic‐British left main revascularization] study and the EXCEL [Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization] trial ) and observational studies with propensity‐score analysis of PCI with DES (DES‐PCI) versus CABG for LMCAD have recently reported mid‐ to long‐term results. Propensity‐score analysis including matching, stratification, and covariate adjustment is a powerful tool to strengthen causal inferences drawn from observational studies .…”

Two-Year Outcomes after Left Main Coronary Artery Percutaneous Coronary Intervention in Patients Presenting with Acute Coronary Syndrome

“…Several studies found that, although patients with AMI and thrombosis in unprotected LMCA are at high-risk for substantial mortality, PCI is still associated with a remarkably high short-term and long-term survival rates [11][12][13]. Moreover, in another study reported by Gao et al [14], transradial PCI on unprotected LMCA and/or multivessel disease for patients with ACS had comparable clinical outcomes to CABG, with an advantage of reducing stroke. Contrarily, Baek et al [15] found patients with ST elevation myocardial infarction (STEMI) and LMCA PCI had poor clinical outcome, which is attributable to periprocedural hemodynamic deterioration.…”