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Hybrid Revascularization a Promising Option for Diabetic Patients

By L.A. McKeown

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A hybrid procedure combining percutaneous revascularization with minimally invasive coronary artery grafting results in similar short-term and midterm mortality and complications compared with coronary artery bypass graft (CABG) surgery in patients with diabetes, according to a study published online July 14, 2014, ahead of print in the American Heart Journal. Additionally, hybrid-treated patients had shorter hospital stays and less need for blood products.

Methods
Ralf E. Harskamp, MD, of Duke Clinical Research Institute (Durham, NC), and colleagues examined data of 103 patients with diabetes (insulin- or noninsulin-dependent) scheduled for a planned nonsternal LIMA-LAD bypass with PCI of at least 1 non-LAD lesion. Hybrid revascularization was carried out either in a single setting (3.9%) or as a 2-stage procedure in which either PCI (18.4%) or CABG (77.7%) was performed first.  
The majority of hybrid cases (81.6%) were performed during the same hospitalization with a median time of 3 days between the 2 stages. LIMA harvest was performed using a Da Vinci robot (Intuitive Surgical; Sunnyvale, CA) and PCI was performed using standardized methods and techniques, mostly involving either first- (sirolimus and paclitaxel) or second-generation (everolimus and zotarolimus) DES.  
Hybrid patients were propensity matched in a 1:5 ratio to 515 CABG-treated patients.  

Comparable Mortality at 30 Days, Midterm

At 30 days, the composite of death, MI, and stroke (primary endpoint) as well as its individual components were similar between the hybrid-revascularization and CABG groups.

In-hospital complications such as renal failure, need for reoperation, and prolonged ventilation also were similar, but there was less use of blood products and chest tube drainage in the hybrid group as well as faster postoperative recovery as demonstrated by shorter postoperative hospital length of stay (table 1).

Table 1. Short-term Clinical Outcomes

 

Hybrid Procedure

(n = 103)

CABG

(n = 515)

P Value

30 Days

    Primary Endpoint

    Death

    MI

    Stroke

 

4.9%

1.9%

1.0%

1.9%

 

3.9%

1.9%

0.8%

1.7%

 

.66

1.00

.84

.89

In-Hospital

    Renal Failure

    Reoperation

    Prolonged Ventilation (> 24 hrs)

    Use of Blood Products

    Chest Tube Drainage (mL/24 hrs)

    Length of Stay < 5 Days

 

3.9%

6.8%

7.8%

29.1%

650

47.6%

 

4.7%

4.9%

10.7%

59.8%

935

29.1%

 

.74

.43

.40

< .0001

< .0001

.003
 

Additionally, mortality after a median follow-up of 2.9 years was similar after the hybrid procedure and CABG (12.3% vs 14.9%; P = .86).

In sensitivity analysis matching patients on an intention-to-treat basis for the hybrid procedure (n = 118) and CABG (n = 590), the primary endpoint (4.2% vs 3.2%; P = .59) and 3-year mortality (16.3% vs 15.2%; P = .38) remained similar between groups.

Crucial Bypass Element Leads to Better Outcomes

The study authors point out that while the FREEDOM trial and others found lower rates of mortality after CABG than PCI in patients with diabetes, the hybrid procedure “may provide an attractive alternative to both multivessel PCI and CABG in diabetic patients.”

They also express little surprise that survival rates after the combined procedure would be equivalent to CABG since the LIMA-to-LAD graft used in hybrid cases has been linked to improved survival with CABG over PCI.

According to Dr. Harskamp and colleagues, careful selection of patients for the hybrid procedure is important to optimize long-term clinical outcomes. For example, diabetic patients with complex lesions, including multi-segment and diffuse disease located in non-LAD territories, may be better candidates for conventional CABG surgery, they add.

In an email with TCTMD, Stephen G. Ellis, MD, of the Cleveland Clinic (Cleveland, OH), said that while the conclusions are reasonable, the study is underpowered and “missing several key angiographic parameters such as Syntax score and [prevalence of] diffuse disease.”

He added that not only is propensity matching associated with major limitations, but the authors “do not provide C-statistics for the model nor propensity-score distribution, so it’s very hard to assess methodology (there are usually reasons why a patient is referred for one procedure or another).”

 

 

 Source:

 

Harskamp RE, Walker PF, Alexander JH, et al. Clinical outcomes of hybrid coronary revascularization versus coronary artery bypass surgery in patients with diabetes mellitus. Am Heart J. 2014;Epub ahead of print.

Disclosures:

  •  Dr. Harskamp reports no relevant conflicts of interest.
  •  Dr. Ellis reports serving as a consultant for Abbott Vascular, Boston Scientific, and Medtronic.

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