Long-term safety and efficacy of percutaneous coronary intervention with stenting and coronary artery bypass surgery for multivessel coronary artery disease: a meta-analysis with 5-year patient-level data from the ARTS, ERACI-II, MASS-II, and SoS trials

Competing risk analysis of events 10 years after revascularization

OBJECTIVES

To evaluate the influence of competing risk (CR) non-cardiac death during long-term follow-up of revascularized patients on the interpretation of the cardiac outcomes.

METHODS

Retrospectively, we compared outcomes estimated with the Kaplan-Meier and the cumulative incidence function (CIF) methods after a median 10.8 years follow-up in 1,234 consecutive patients (594 CABG, 640 PCI) undergoing first time non-emergent revascularization in a community cohort.

RESULTS

Overall 301 (24.4%) patients died (27.3% in the CABG vs. 21.7% in the PCI group, p = 0.02). The causes of death were cardiac (10.3%) and non-cardiac (14.1%). CR analysis showed a similar probability of cardiac death (CIF 0.10 (95% CI 0.092, 0.18) vs. 0.093 (0.07, 0.12)) in the CABG and PCI treated patients, respectively. The probability for acute myocardial infarction (CIF 0.12 vs. 0.16 p < 0.001), congestive heart failure (CIF 0.15 vs. 0.09 p = 0.007) in the CABG and PCI group respectively, differed. The differences were also statistically significant after multivariate adjustment for the competing risks of death. For all outcomes the Kaplan-Meier method overestimated risk estimates.

CONCLUSIONS

The competing risk adjusted probability for cardiac death, but not other cardiac endpoints are comparable in patients treated with either CABG or PCI after very long-term follow-up. The risk for all-cause death was mainly predicted by the occurrence of non-cardiac diseases.

Percutaneous coronary intervention with drug-eluting stents versus coronary artery bypass surgery for multivessel coronary artery disease: a meta-analysis of data from the ARTS II, CARDia, ERACI III, and SYNTAX studies and systematic review of observational data

AIMS

The aim of this study was to systematically analyse the available data from trials comparing revascularisation by drug-eluting stent (DES) placement versus coronary artery bypass grafting (CABG) in patients with multivessel coronary artery disease (CAD).

METHODS AND RESULTS

We searched PubMed, Medline and several internet sources for randomised controlled trials comparing DES placement to CABG in patients with multivessel coronary artery disease. There were no restrictions on journal type or population studied. Prior to data collection we chose to analyse the prospectively performed trials separately from data obtained retrospectively. Four prospective trials were identified which enrolled a total of 3,895 patients: 1,914 in the DES arm and 1,981 patients in the CABG arm. Pooled analysis of data from these four studies showed that in patients treated DES compared to CABG there was a similar risk of the combined endpoints of death, myocardial infarction and stroke (10.2% versus 10.8%, respectively; RR=0.94 [95% CI=0.77-1.116]; p=0.56), but a significantly higher risk of target vessel revascularisation (TVR) (14.6% versus 6.8%, respectively; RR=2.09 [95% CI=1.72-2.55]; <0.001) and, therefore, a significantly higher risk of MACCE (21.2% versus 16.3%, respectively; RR=1.27 [95% CI=1.09-1.48]; p=0.002). Interestingly, when MACCE rates at one year are used for these trials the risk is equivalent between DES and CABG (14.4% versus 12.5%, respectively; RR=1.05 [95% CI=0.70-1.57]; p=0.83). Analysis of observational data revealed similar findings.

CONCLUSIONS

Overall, PCI with DES placement was safe in patients with multivessel disease compared to CABG, but is associated with a significantly higher risk of TVR.

Local arterial nanoparticle delivery of siRNA for NOX2 knockdown to prevent restenosis in an atherosclerotic rat model

Both atherosclerosis and arterial interventions induce oxidative stress mediated in part by nicotinamide adenine dinucleotide phosphate (NADPH) oxidases that have a pivotal role in the development of neointimal hyperplasia and restenosis. For small interfering RNA (siRNA) targeting of the NOX2 (Cybb) component of the NADPH oxidase to prevent restenosis, gene transfer with viral vectors is effective, but raises safety issues in humans. We developed a new approach using the amino-acid-based nanoparticle HB-OLD7 for local delivery of siRNA targeting NOX2 to the arterial wall. siRNA-nanoparticle complexes were transferred into the regional carotid artery walls after angioplasty in an atherosclerotic rat model. Compared with angioplasty controls, Cybb gene expression (measured by quantitative reverse transcriptase-PCR) in the experimental arterial wall 2 weeks after siRNA was reduced by >87%. The neointima-to-media-area ratio was decreased by >83%, and the lumen-to-whole-artery area ratio was increased by >89%. Vital organs showed no abnormalities and splenic Cybb gene expression showed no detectable change. Thus, local arterial wall gene transfer with HB-OLD7 nanoparticles provides an effective, nonviral system for efficient and safe local gene transfer in a clinically applicable approach to knock down an NADPH oxidase gene. Local arterial knockdown of the Cybb gene significantly inhibited neointimal hyperplasia and preserved the vessel lumen without systemic toxicity.

Emerging drugs for coronary restenosis: the role of systemic oral agents the in stent era

Introduction of drug eluting stents (DES) during percutaneous coronary interventions significantly reduces the rate of angiographic restenosis, target lesion and vessel revascularization. In spite of these benefits, other clinical hard end points such as death or myocardial infarction were not reduced and, furthermore, new concerns associated with the presence of late and very late stent thrombosis have been raised. The requirement of long-term dual antiplatelet therapy is another limitation associated with DES. Conversely, in this decade, other options to DES have been simultaneously discussed in observational and randomized studies. Several registries and randomized trials using the systemic approach with anti-inflammatory, immunosuppressive or antiplatelet therapies have been identified and discussed in this manuscript. In spite of all randomized studies with oral therapies in the bare metal stent (BMS) era demonstrating positive reductions in coronary restenosis, this practice has not been introduced clinically. Furthermore, a recent randomized trial comparing oral sirolimus plus BMS versus DES demonstrated that the first approach was cost saving and of comparable efficacy to DES. Conclusive evidence of high incidence of late and very late stent thrombosis with DES, together with clinical limitations for its widespread use, has opened up a large opportunity to search for alternative therapies in coronary restenosis prevention.

The role of CABG in the era of drug-eluting stents: a surgeon's viewpoint

Advances in transcatheter technologies, from balloon angioplasty to bare metal stents to drug-eluting stents, have resulted in improved outcomes following percutaneous coronary intervention (PCI). As a consequence, the differences in outcomes between coronary artery bypass graft surgery (CABG) and PCI have become less significant over short-term follow-up. In addition, the number of patients undergoing coronary revascularisation with PCI has increased and far exceeds that of CABG, which has declined, the ratio stabilising in recent years. With the advent of drug-eluting stents and the increasing off-label use of these stents-and in the setting of questionable public awareness of the relative risks and benefits of the therapeutic options of optimal medical treatment and revascularisation by PCI or CABG-the role of CABG requires clarification and reaffirmation. Recent clinical trials have helped to better define the relative benefits of each treatment modality. The mid- and long-term results of these studies remain to be seen, however, while the evidence for the role of PCI in left main stem disease remains inconclusive at the present time. In this context of continually emerging clinical evidence, this review seeks to provide a balanced opinion regarding the role of CABG in the era of drug-eluting stents.

Chronic coronary artery disease: diagnosis and management

Coronary artery disease (CAD) is the single most common cause of death in the developed world, responsible for about 1 in every 5 deaths. The morbidity, mortality, and socioeconomic importance of this disease make timely accurate diagnosis and cost-effective management of CAD of the utmost importance. This comprehensive review of the literature highlights key elements in the diagnosis, risk stratification, and management strategies of patients with chronic CAD. Relevant articles were identified by searching the PubMed database for the following terms: chronic coronary artery disease or stable angina. Novel imaging modalities, pharmacological treatment, and invasive (percutaneous and surgical) interventions have revolutionized the current treatment of patients with chronic CAD. Medical treatment remains the cornerstone of management, but revascularization continues to play an important role. In the current economic climate and with health care reform very much on the horizon, the issue of appropriate use of revascularization is important, and the indications for revascularization, in addition to the relative benefits and risks of a percutaneous vs a surgical approach, are discussed.

Drug-eluting stents and the use of percutaneous coronary intervention among patients with class I indications for coronary artery bypass surgery undergoing index revascularization: analysis from the NCDR (National Cardiovascular Data Registry)

OBJECTIVES

Our purpose was to evaluate percutaneous coronary intervention (PCI) attempt rates in patients with class I indications for coronary artery bypass graft (CABG) surgery after the introduction of drug-eluting stents (DES).

BACKGROUND

In patients with severe, multivessel coronary disease, CABG has historically been recommended over PCI. Practice guidelines for CABG were last updated before the emergence of data on DES efficacy.

METHODS

We analyzed 265,028 procedures from the NCDR (National Cardiovascular Data Registry) meeting American College of Cardiology/American Heart Association class I indications for surgical revascularization. Temporal trends in PCI attempt rates were analyzed during 3 consecutive time periods: pre-DES (before April 1, 2003), DES diffusion (April 1, 2003 to December 31, 2004), and DES (January 1, 2005 to September 30, 2006).

RESULTS

The attempted rate of PCI in patients with class I indications for CABG increased over the 3 time periods (pre-DES: 29.4%, DES diffusion: 33.4%, and DES era: 34.7%, p < 0.001). In a hierarchical multivariable logistic model adjusting for patient and PCI site characteristics, PCI attempts were more likely in the DES compared with pre-DES era (odds ratio: 1.44, 95% confidence interval: 1.40 to 1.48) and the DES diffusion era (odds ratio: 1.20, 95% confidence interval: 1.17 to 1.23). PCI attempt rates increased in all 3 time periods, although the average rate of increase during the DES era was 0.6% per quarter compared with 0.3% per quarter for both the DES diffusion and the pre-DES eras (p = 0.03).

CONCLUSIONS

DES use in clinical practice was associated with a significant overall increase in PCI to treat patients with class I indications for CABG. Long-term follow-up of this cohort of patients is warranted.

Four-year outcome of OPCAB no-touch with total arterial Y-graft: making the best treatment a daily practice

BACKGROUND

A retrospective, single-center 4-year clinical study of the off-pump coronary artery bypass grafting no-touch technique with arterial conduits (Y-graft) was compared with the Syntax trial.

METHODS

Four hundred consecutive patients ("all-comers") who underwent coronary surgery between 2004 and 2008 at the Thorax Center Twente (TCT) formed the study group. The primary end point was in-hospital and 12-month major cardiovascular or cerebrovascular event (MACCE). Event rates of MACCE were based on life tables, and overall MACCE was determined by Kaplan-Meier analysis.

RESULTS

In-hospital mortality was 0.2%. Cumulative 1-year survival was 98.2%, and freedom from MACCE was 94.7% +/- 1.1%. Cumulative 4-year survival and freedom from MACCE were 91.2% +/- 2.4% and 82.1% +/- 3.0%, respectively. There were no significant differences in the baseline characteristics between the patients of the TCT group and the surgical arm of the Syntax trial. Repeat revascularization, MACCE, and symptomatic graft occlusion in the TCT group were significantly lower than in the Syntax trial. The event rate of myocardial infarction and all-cause death in the TCT group were significantly lower than those of the percutaneous coronary intervention arm of the Syntax trial. There was a clear trend toward a reduction of the event rate of stroke in the TCT group (0.8%) compared with the surgical arm of the Syntax trial (2.2%). There was no significant difference of stroke rate between the TCT group and the percutaneous coronary intervention arm of the Syntax trial.

CONCLUSIONS

A state-of-the-art surgical technique such as off-pump coronary artery bypass grafting no-touch can further improve the advantage of surgical treatment with respect to percutaneous coronary intervention. Off-pump coronary artery bypass grafting no-touch surgery can be the treatment of choice for patients with three-vessel disease and left main stenosis.

Coronary revascularization for patients with unprotected left main coronary artery disease: evidence, guidelines, and judgment! Making clinical decisions in 2009

The current clinical practice guidelines categorize the use of coronary artery bypass graft (CABG) surgery for revascularization of patients with unprotected left main coronary artery disease (ULMCAD) as a class IA recommendation while it categorize the use of percutaneous coronary interventions (PCI) as a class III recommendation. The evidence underlying these recommendations is weak and out dated. The purpose of this review is to critically reevaluate current state-of-the-art with respect to revascularization of patients with ULMCAD who are acceptable surgical candidates. In doing so we will highlight the divergence between practice guidelines and patient-centered clinical decision-making; critically appraise the "evidence" underlying the current practice guidelines; review the emerging data regarding utility of CABG versus PCI in these patients; and finally discuss the elements of a contemporary approach to clinical decision-making in light of the current state of knowledge.

Recent advances in the management of coronary artery disease: highlights from the literature

The recent advances in the multidisciplinary management of coronary artery disease (CAD) have been significant. The assessment of patients before percutaneous coronary intervention is likely to change significantly. National compliance with clinical guidelines in the preprocedural assessment of myocardial ischemia should be encouraged. Multislice computed tomographic coronary angiography continues to improve and is already an excellent screening test for CAD. Coronary stenting has an increasing role in multivessel and left main CAD, although further outcome trials are indicated, especially in the elderly. Although off-pump coronary artery bypass graft (CABG) surgery reduces postoperative atrial fibrillation, further major outcome advantages have not been shown in comprehensive meta-analyses when compared with on-pump CABG surgery. Although an intra-aortic balloon pump reduces mortality in high-risk CABG surgery, it may be replaced gradually by the percutaneous left ventricular-assist device, which has shown clinical benefit in this challenging setting. Statin therapy significantly improves clinical outcome after CABG surgery, even when begun postoperatively. There is strong evidence that, unless contraindicated, all CABG patients should receive statin therapy. Clopidogrel therapy just before CABG surgery is still associated with prolonged hospital stay because of significant bleeding complications. This risk will be exacerbated with the advent of the more potent platelet inhibitor, prasugrel. There is a clinical necessity for readily reversible platelet blockade to minimize the bleeding risks in CABG surgery.

Quantitative results of baseline angiography and percutaneous coronary intervention in the COURAGE trial

BACKGROUND

COURAGE compared outcomes in stable coronary patients randomized to optimal medical therapy plus percutaneous coronary intervention (PCI) versus optimal medical therapy alone.

METHODS AND RESULTS

Angiographic data were analyzed by treatment arm, health care system (Veterans Administration, US non-Veterans Administration, Canada), and gender. Veterans Administration patients had higher prevalence of coronary artery bypass graft surgery and left ventricular ejection fraction < or =50%. Men had worse diameter stenosis of the most severe lesion, higher prevalence of prior coronary artery bypass graft surgery, lower left ventricular ejection fraction, and more 3-vessel disease that included a proximal left anterior descending lesion (P<0.0001 for all comparisons versus women). Failure to cross rate (3%) and visual angiographic success of stent procedures (97%) were similar to contemporary practice in the National Cardiovascular Data Registry. Quantitative angiographic PCI success was 93% (residual lesion <50% in-segment) and 82% (<20% in-stent), with only minor nonsignificant differences among health care systems and genders. Event rates were higher in patients with higher jeopardy scores and more severe vessel disease, but rates were similar irrespective of treatment strategy. Within the PCI plus optimal medical therapy arm, complete revascularization was associated with a trend toward lower rate of death or nonfatal myocardial infarction. Complete revascularization was similar between genders and among health care systems.

CONCLUSIONS

PCI success and completeness of revascularization did not differ significantly by health care system or gender and were similar to contemporary practice. Angiographic burden of disease affected overall event rates but not response to an initial strategy of PCI plus optimal medical therapy or optimal medical therapy alone.

First-in-man (FIM) study of the Stentys bifurcation stent--30 days results

AIMS

We report the acute and 30 day results of the OPEN I study, a multicentre prospective single arm study evaluating the safety and feasibility of the Stentys bifurcation stent.

METHODS AND RESULTS

The Stentys stent is a provisional, self-expanding nitinol drug eluting or bare metal stent with small interconnections that can be disconnected by balloon angioplasty to provide access to the side-branch and full ostium coverage. Forty patients with de novo coronary bifurcation lesions were enrolled to be clinically followed-up over four years. In addition to angiographic QCA evaluation, documentary IVUS and/or OCT were used in all cases to assess the stent's deployment. The patient population consisted of 85% males with an average age of 62 years. Almost half had previous PCI, 31% previous MI and 5% previous CABG. The majority of lesions (80%) involved the LAD-D, 42% of the patients had disease affecting the side-branch, with all three arms diseased in 24% of the cases. The average lesion length in the main branch was 12.95 +/- 3.63 mm with a bifurcation angle of 55 degrees (range 30 degrees - 80 degrees). Procedural success was achieved in 39/40 cases (95.5%) due to inability to track the stent in one patient with an extremely tortuous vessel. In total 6 (15%) paclitaxel eluting and 33 (85%) BMS Stentys stents were successfully implanted, and simple disconnection of the stent mesh overlying the SB ostium was achieved in 37/39 cases (94.9%); in two cases, disconnection was not attempted. The MACE at 30 days was 5.1% as a result of one non Q-wave MI following the procedure and one ischemia-driven revascularisation six days after the procedure.

CONCLUSIONS

This first-in-man (FIM) study demonstrates that the Stentys stent is safe and feasible resulting in an excellent procedural success rate and a low MACE rate. The struts can be easily and safely disconnected to perform provisional stenting.

Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease

BACKGROUND

Percutaneous coronary intervention (PCI) involving drug-eluting stents is increasingly used to treat complex coronary artery disease, although coronary-artery bypass grafting (CABG) has been the treatment of choice historically. Our trial compared PCI and CABG for treating patients with previously untreated three-vessel or left main coronary artery disease (or both).

METHODS

We randomly assigned 1800 patients with three-vessel or left main coronary artery disease to undergo CABG or PCI (in a 1:1 ratio). For all these patients, the local cardiac surgeon and interventional cardiologist determined that equivalent anatomical revascularization could be achieved with either treatment. A noninferiority comparison of the two groups was performed for the primary end point--a major adverse cardiac or cerebrovascular event (i.e., death from any cause, stroke, myocardial infarction, or repeat revascularization) during the 12-month period after randomization. Patients for whom only one of the two treatment options would be beneficial, because of anatomical features or clinical conditions, were entered into a parallel, nested CABG or PCI registry.

RESULTS

Most of the preoperative characteristics were similar in the two groups. Rates of major adverse cardiac or cerebrovascular events at 12 months were significantly higher in the PCI group (17.8%, vs. 12.4% for CABG; P=0.002), in large part because of an increased rate of repeat revascularization (13.5% vs. 5.9%, P<0.001); as a result, the criterion for noninferiority was not met. At 12 months, the rates of death and myocardial infarction were similar between the two groups; stroke was significantly more likely to occur with CABG (2.2%, vs. 0.6% with PCI; P=0.003).

CONCLUSIONS

CABG remains the standard of care for patients with three-vessel or left main coronary artery disease, since the use of CABG, as compared with PCI, resulted in lower rates of the combined end point of major adverse cardiac or cerebrovascular events at 1 year. (ClinicalTrials.gov number, NCT00114972.)