CABG vs. PCI for Multivessel CAD: Do Second-Generation Stents Make a Difference?

Summary and Comment |
March 16, 2015

CABG vs. PCI for Multivessel CAD: Do Second-Generation Stents Make a Difference?

  1. Howard C. Herrmann, MD

Second-generation stents narrow the gap between the two revascularization strategies for nondiabetic patients with multivessel disease.

  1. Howard C. Herrmann, MD

For multivessel coronary artery disease (CAD), coronary artery bypass grafting (CABG) generally has lower rates of myocardial infarction (MI) and repeat revascularization than percutaneous coronary intervention (PCI), even with drug-eluting stents (DESs); CABG also has shown a trend toward better survival as CAD complexity increases but a higher rate of stroke. Two manufacturer-supported studies reexamine this issue in the era of safer, more-effective second-generation DESs.

In a noninferiority, multicenter study, 880 Asian patients with multivessel CAD (77% with 3-vessel) were randomized to CABG or PCI with everolimus-eluting stents (EESs). The study was stopped prematurely due to slow enrollment. PCI patients received an average of 3.4 stents; >99% of CABG patients received an internal thoracic artery graft to the left anterior descending artery. Complete revascularization was achieved more often with CABG than PCI (72% vs. 51%). At 2 years, the primary endpoint (death, MI, or target-vessel revascularization) was similar between groups (PCI, 11%; CABG, 8%), although the difference became statistically significant by 5 years (15% vs. 11%), due primarily to more repeat revascularizations and a trend toward more MIs with PCI. On the primary endpoint, treatments did not differ in nondiabetic patients (hazard ratio, 1.07) but showed a pronounced difference in diabetics (HR, 2.24).

In an observational comparison, investigators used New York State registry data and propensity matching to compare outcomes in 9223 patients with multivessel disease undergoing PCI with EESs and 9223 patients undergoing CABG. Early 30-day mortality and stroke were superior with PCI (death: 0.6% vs. 1.1% with CABG; stroke: 0.2% vs. 1.2%). At a mean follow-up of 2.9 years, the groups, including a diabetes subgroup, had similar mortality. Subsequent spontaneous MI was about 1% annually more frequent after PCI than after CABG, but only when revascularization was incomplete. Repeat revascularization was more common after PCI (7.2% vs. 3.1%).

Comment

These studies provide a wealth of data informing clinicians and patients about the differences between CABG and PCI for multivessel CAD. PCI may offer early safety benefits for stroke, bleeding, and potentially, mortality but poses a greater need for repeat revascularization (even with second-generation DESs). Later mortality is similar with the two procedures, but MI rates may be higher after PCI. Overall, these data suggest few differences, except for patients with diabetes and for those in whom complete revascularization cannot be attained. This gives the edge to the less invasive approach, which most patients tend to prefer.

Editor Disclosures at Time of Publication

  • Disclosures for Howard C. Herrmann, MD at time of publication Consultant / Advisory board Gerson Lehrman Group; Siemens; St. Jude Medical; Leerink Swann; Wells Fargo; Massachusetts Medical Society; Morgan Stanley; Edwards Lifesciences Speaker's bureau Society of Cardiovascular Angiography and Interventions; Montefiore Medical Center; American Association for Thoracic Surgery Equity Micro-Interventional Devices, Inc. Grant / Research support Abbott Vascular; Edwards Lifesciences; Gore; Medtronic; St. Jude Medical; Siemens; Boston Scientific; Regado Biosciences; Cordis; Cardiokinetix; University of Laval; MitraSpan Editorial boards Catheterization and Cardiovascular Interventions; Circulation-Cardiovascular Interventions; Journal of Interventional Cardiology; Journal of Invasive Cardiology

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