CABG, DES Yield Similar Outcomes in Isolated Proximal LAD Disease
Contemporary hard clinical outcomes are comparable after CABG and PCI for patients with isolated proximal LAD disease, according to a retrospective study published in the December 30, 2014, issue of the Journal of the American College of Cardiology. Repeat revascularization, however, is more frequent with PCI.
Edward L. Hannan, PhD, of the University at Albany (Albany, NY), and colleagues examined data from several New York State sources: clinical registries for PCI and CABG, the Percutaneous Coronary Interventions Reporting System, and the Cardiac Surgery Reporting System. The study included 6,064 patients who underwent revascularization for single-vessel proximal LAD disease at 57 hospitals from 2008 through 2010; 88% underwent PCI with DES and the rest underwent CABG.
At 3 years, patients who received DES had lower unadjusted rates of all-cause mortality (4.3% vs 5.9%) and a composite of mortality, MI, or stroke (6.1% vs 8.3%), but higher rates of repeat revascularization (12.2% vs 6.5%).
But after propensity matching, which left 715 patients each who underwent PCI or CABG, and adjustment with Cox proportional hazards models, there were no differences in hard clinical outcomes; repeat revascularization remained lower with CABG (table 1).
The findings were similar in analyses restricted to diabetic patients and to those with no history of MI.
Guidelines Offer Little Help
Recent ACC/AHA/SCAI guidelines give CABG a class IIa recommendation for patients with isolated proximal LAD disease when performed with a left internal mammary artery graft. That recommendation is slightly stronger than the one for PCI (class IIb), although more recent appropriate use criteria for coronary revascularizations do not rank CABG vs PCI when indicated in these patients.
Prior studies comparing CABG and PCI for single-vessel proximal LAD disease were mostly done in the pre-DES era, although they generally showed a lack of a difference in hard outcomes and lower repeat revascularization rates with CABG.
“This may be because most enrolled patients were younger and healthier, had better left ventricular function and lesser comorbidities, and commonly underwent elective or (at the most) urgent procedures,” explain Friederich W. Mohr, MD, PhD, and Piroze M. Davierwala, MD, of the University of Leipzig Heart Center (Leipzig, Germany), in an accompanying editorial.
“Because such low-risk patients experience fewer early and late procedure-related deaths, larger numbers would need to be treated to elicit a significant difference in mortality,” they continue. “Moreover, follow-up periods in all but 1 trial and in most studies, including the current study, were too short to reveal a survival advantage favoring surgery.”
Information on Angina, Lesions Needed
Although the current study “confirms repeat TVR as the Achilles heel of PCI, even in the era of DES,” Drs. Mohr and Davierwala write, it does have some drawbacks.
First, the study did not include information on angina recurrence, which has been shown to be more frequent after PCI. “Recurrent angina and repeat TVR reduce quality of life and result in repeated hospital admissions, thus escalating the long-term costs of PCI that offset theinitially higher costs of surgery,” they write.
And second, there also was no information on lesion complexity, “a primary prerequisite in deciding on the optimal choice of therapy,” they write.
“PCI is extremely challenging in patients with calcified, occluded, or bifurcation lesions and highly tortuous vessels, and, in such cases, is associated with higher rates of procedural failure and suboptimal results,” the editorialists note. “Conversely, CABG procedural success and prognosis is determined by vessel quality at the anastomotic site and the distal coronary tree.”
Therefore, a heart team approach would be best for “patients with borderline lesions and multiple comorbidities,” they conclude.
1. Hannan EL, Zhong Y, Walford G, et al. Coronary artery bypass graft surgery versus drug-eluting stents for patients with isolated proximal left anterior descending disease. J Am Coll Cardiol. 2014;64:2717-2726.
2. Mohr FW, Davierwala PM. Revascularization strategy for proximal LAD disease: left internal mammary to LAD artery still rules the roost [editorial]. J Am Coll Cardiol. 2014;64:2727-2729.
- Drs. Davierwala, Hannan, and Mohr report no relevant conflicts of interest.