Stenting of the Left Main Artery Is Noninferior to Bypass Surgery

November 1, 2016

Stenting of the Left Main Artery Is Noninferior to Bypass Surgery

  1. Howard C. Herrmann, MD

A large randomized trial demonstrates equivalent 3-year outcomes in selected patients with left main coronary artery disease.

  1. Howard C. Herrmann, MD

Unprotected left main (LM) coronary artery disease (CAD) has traditionally been treated surgically with coronary-artery bypass grafting (CABG), although the SYNTAX trial suggested similar outcomes with percutaneous coronary intervention (PCI) using first-generation stents in a subset of patients with low or intermediate CAD burden. Now, the manufacturer-funded, randomized, noninferiority EXCEL trial has compared PCI using a contemporary drug-eluting stent to CABG using contemporary techniques in 2905 patients with angiographic LM lesions ≥70% or hemodynamically significant lesions ≥50% (mean baseline age, 66; men, 77%; diabetes, 29%; distal LM bifurcation lesions, 80%; 2- or 3-vessel disease, 51%). Overall CAD burden was low or intermediate (i.e., SYNTAX score, ≤32; 60.5% and 39.5%, respectively).

Patients received a mean of either 2.4 stents or 2.6 grafts (internal thoracic artery grafts, 99%). Intravascular ultrasound guidance was used in nearly 80% of PCI patients. After a median follow-up of 3 years, the primary composite endpoint (death, stroke, or myocardial infarction) occurred in 15.4% of PCI patients and 14.7% of CABG patients, showing noninferiority; the endpoint also did not differ in prespecified subgroups including diabetics and patients with angiographically-determined high SYNTAX scores (24%). A composite outcome at 30 days occurred significantly less frequently with PCI than with CABG (4.9% vs. 7.9%). Ischemia-driven revascularization was more frequent after PCI (12.6% vs. 7.5%); definite stent thrombosis post-PCI was less frequent than symptomatic graft occlusion post-CABG (0.7% vs. 5.4%).

Comment

At 3 years, PCI and CABG did not differ on the composite main outcome for these selected patients with LM disease and low and intermediate SYNTAX scores. Early major adverse events were 15 percentage points more common with CABG; late revascularization was 5 percentage points more common after PCI. As an editorialist notes, longer follow-up is necessary to assess a trend of more events with PCI than with CABG between 30 days and 3 years. However, these results, particularly the early benefit and faster recovery, will likely prompt many more patients and physicians to choose PCI over CABG.

Editor Disclosures at Time of Publication

  • Disclosures for Howard C. Herrmann, MD at time of publication Consultant / Advisory board Gerson Lehrman Group; Leerink Swann; Wells Fargo; Edwards Lifesciences; Coleman Research Group Speaker's bureau American College of Cardiology Foundation; American Association for Thoracic Surgery; Beaumont Hospital Cardiovascular Research Foundation; Inova Health Care; Medintelligence; Medinol; Society for Cardiovascular Angiography and Interventions; Northwestern University; Washington Hospital St. Louis; Westchester Medical Center Equity Micro Interventional Devices, Inc. Grant / Research support Abbott Vascular; Boston Scientific; Edwards Lifesciences; St. Jude Medical; Medtronic; Gore; Siemens; Cardiokinetix; University of Laval; Mitraspan Editorial boards Catheterization and Cardiovascular Interventions; Circulation: Cardiovascular Interventions; Journal of Interventional Cardiology; Journal of Invasive Cardiology; Journal of the American College of Cardiology

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Reader Comments (1)

JOHN GRAY

Since most of my patients would like to live longer than 3 years, I hope that this study will continue for 10-15 years.

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