Revascularization of Left Anterior Descending Artery With Drug-Eluting Stents: Comparison With Minimally Invasive Direct Coronary Artery Bypass Surgery

Alternative Approaches to Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention, How Do They Compare?: A Systematic Review and Meta-Analysis

Coronary artery disease (CAD) is a leading cause of mortality worldwide. Severe symptomatic CAD is treated with coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). Alternative CABG (ACABG) approaches including thoracotomy, off-pump, total endoscopic, and robotic-assisted CABG are increasing in prevalence to address the increased early risk of CABG. This systematic review and meta-analysis aims to review the contemporary literature comparing outcomes after ACABG and PCI. Pubmed, Medline, and Embase were systematically searched by 2 authors for articles comparing the outcomes after ACABG and PCI. A total of 1154 articles were screened, and 11 were included in this review. The RevMan 5.4 software was used to perform a meta-analysis of the pooled data. Individual studies found rates of long-term survival, major adverse cardiovascular and cerebrovascular events (MACCE), myocardial infarction (MI), and repeat revascularization either favored ACABG or did not differ significantly. Pooled estimates of the compiled data identified rates of MACCE, MI, and repeat revascularization favored ACABG. The results of this review demonstrated the favorable rates of long-term mortality, MACCE, MI, and repeat revascularization for ACABG in addition to similar short-term mortality and stroke when compared with PCI. Advancement of both CABG and PCI continues to improve patient outcomes. With the increasing prevalence of ACABG, similar studies will need to be undertaken with further direct comparisons between ACABG and PCI. Finally, hybrid revascularization should continue to be explored for its combined benefits of long-term outcomes, short-term safety, and ability to achieve complete revascularization.

Minimally invasive surgery or stenting for left anterior descending artery disease - meta-analysis

Minimally invasive direct coronary artery bypass (MIDCAB) surgery and percutaneous coronary intervention (PCI) are both well-established minimally invasive revascularization strategies in patients with proximal left anterior descending (LAD) lesions. We aimed to evaluate the 20-years' experience by performing a systematic review and meta-analysis comparing MIDCAB versus PCI in adults with proximal LAD disease. We searched MEDLINE, EMBASE and Cochrane on October 1st, 2021 for articles published in the year 2000 or later. The primary outcome was all-cause mortality. Secondary outcomes included cardiac mortality, repeat target vessel revascularization (rTVR), myocardial infarction (MI), and cerebrovascular accident (CVA). Outcomes were analysed at short-term, mid-term, and long-term follow-up. Random effects meta-analyses were performed. Events were compared using risk ratios (RR) with 95% confidence intervals (CI). Our search yielded 17 studies pooling 3847 patients. At short-term follow-up, cardiac mortality was higher with MIDCAB than with PCI (RR 7.30, 95% CI: 1.38 to 38.61). At long-term follow-up, MIDCAB showed a decrease in all-cause mortality (RR 0.66, 95% CI: 0.46 to 0.93). MIDCAB showed a decrease in rTVR at mid-term follow-up (RR 0.16, 95% CI: 0.11 to 0.23) and at long-term follow-up (RR 0.25, 95% CI: 0.17 to 0.38). MI and CVA comparisons were not significant. In conclusion, in patients with proximal LAD lesions, MIDCAB showed a higher short-term mortality in the RCTs, but the cohort studies suggested a lower all-cause mortality at long-term follow-up. We confirm a decreased rTVR at mid-term follow-up in the RCTs and long-term follow-up in the cohort studies.

Minimally invasive and robotic coronary artery bypass grafting-a 25-year review

During the mid-1990s cardiac surgery started exploring minimally invasive methods for coronary artery bypass grafting (CABG) and has over a 25-year period developed highly differentiated and less traumatic operations. Instead of the traditional sternotomy mini-incisions on the chest or ports are placed, surgery on the beating heart is applied, sophisticated remote access heart lung machine systems as well as videoscopic units are available, and robotic technology enables completely endoscopic approaches. This review describes these methods, reports on the cumulative intra- and postoperative outcome of these procedures, and gives an integrated view on what less invasive coronary bypass surgery can achieve. A total of 74 patient series published on the topic between 1996 and 2019 were reviewed. Six main versions of minimal access and robotically assisted CABG were applied in 11,135 patients. On average 1.3±0.6 grafts were placed and the operative time was 3 hours 42 min ± 1 hour 15 min. The procedures were carried out with a hospital mortality of 1.0% and a stroke rate of 0.6%. The revision rate for bleeding was 2.5% and a renal failure rate of 0.9% was noted. Wound infections occurred at a rate of 1.2% and postoperative hospital stay was 5.6±2.2 days. It can be concluded that less invasive and robotically assisted versions of coronary bypass grafting are carried out with an adequate safety level while surgical trauma is significantly reduced.

Reviewing hybrid coronary revascularization: challenges, controversies and opportunities

Two main approaches to myocardial revascularization currently exist, coronary artery bypass and percutaneous coronary intervention. In patients with advanced coronary artery disease, coronary artery bypass surgery is associated with improved long term outcomes while percutaneous coronary intervention is associated with lower periprocedural complications. A new approach has emerged in the last decade that attempts to reap the benefits of bypass surgery and stenting while minimizing the shortcomings of each approach. This new approach, hybrid coronary revascularization, has shown encouraging early results. Minimally invasive techniques for bypass surgery have played a large part of bringing this approach into contemporary practice.

Meta-analysis of minimally invasive coronary artery bypass versus drug-eluting stents for isolated left anterior descending coronary artery disease

OBJECTIVE

To compare the outcomes between minimally invasive coronary artery bypass (MINI-CAB) and drug-eluting stent (DES) implantation for isolated left anterior descending artery disease.

METHODS

Randomized and observational comparative publications were identified using MEDLINE and Google Scholar databases (January 2003 to December 2013). Studies without outcomes data, without DES use, or using conventional bypass surgery were excluded. The outcomes of interest were cardiac death, myocardial infarction, target vessel revascularization, and periprocedural stroke. Data were compared using the Mantel-Haenszel methods and are presented as odds ratios (ORs), 95% confidence intervals (CIs), and number needed to treat.

RESULTS

From 230 publications, we identified 4 studies (2 randomized and 2 observational) with 941 patients (478 had undergone MINI-CAB and 463 DES implantation). The incidence of target vessel revascularization at maximum follow-up (range, 6-60 months) was significantly lower in the MINI-CAB group (OR, 0.16; 95% CI, 0.08-0.30; P<.0001; number needed to treat, 13). The incidence of cardiac mortality and MI was similar between the MINI-CAB and DES groups during follow-up (OR, 1.05; 95% CI, 0.44-2.47; and OR, 0.83; 95% CI, 0.43-1.58, respectively). In addition, a similar incidence of periprocedural death (OR, 0.85; 95% CI, 0.21-3.47; P=.82), myocardial infarction (OR, 0.98; 95% CI, 0.38-2.58; P=.97), and stroke (OR, 1.36; 95% CI, 0.28-6.70; P=.70) was observed between the 2 treatment modalities.

CONCLUSIONS

Given the available evidence, MINI-CAB will result in lower target vessel revascularization rates but otherwise similar clinical outcomes compared with DESs in patients with left anterior descending artery disease.

Outcomes after different non-sternotomy approaches to left single-vessel revascularization: a comparative study with up to 10-year follow-up

OBJECTIVES

Various non-sternotomy approaches have been used for left internal mammary artery (LIMA) grafting in left single-vessel revascularization. The aim of this study was to evaluate the impact of three different non-sternotomy techniques on long-term outcomes after left single-vessel revascularization.

METHODS

A total of 502 patients having single-vessel LAD disease treated from April 2003 to May 2013 by minimally invasive direct coronary artery bypass grafting (MIDCAB), endoscopically assisted coronary artery bypass grafting (EACAB) or robotically assisted direct coronary artery bypass grafting (RADCAB) were reviewed. In all cases, distal anastomoses were performed through anterolateral minithoracotomy incisions. In-hospital and long-term (10-year) outcomes were compared using standard and propensity score-adjusted analyses.

RESULTS

One hundred and eighty-nine patients had MIDCAB, 76 had EACAB and 236 had RADCAB. After propensity score matching, RADCAB patients had significantly longer operative duration (P < 0.001), whereas MIDCAB and RADCAB patients had significantly higher incidence of postoperative angina over the follow-up (P = 0.034). The groups were comparable regarding in-hospital mortality and reintervention rate as well as incidence of myocardial infarction, reoperations, reinterventions and cardiac death. All groups showed comparable long-term survival (P = 0.943).

CONCLUSIONS

MIDCAB, EACAB and RADCAB are associated with similar long-term survival and incidence of major adverse cardiac events (MACEs) in single-vessel surgical revascularization. However, the endoscopic approach was found to be free from the disadvantages of longer operating duration observed in RADCAB or higher incidence of angina and shorter freedom from MACEs observed in both MIDCAB and RADCAB groups.

Is off-pump coronary artery bypass grafting superior to drug-eluting stents for the treatment of coronary artery disease? A meta-analysis of randomized and nonrandomized studies

BACKGROUND

As drug-eluting stent (DES) has almost overcome the disadvantage of frequent restenosis, off-pump coronary artery bypass grafting (OPCAB) has been introduced to avoid complications of cardiopulmonary bypass. However, which approach may promise better outcomes for patients with coronary artery disease remains controversial.

METHODS

Three databases were searched. The outcomes of interest were major adverse cardiac and cerebrovascular events (MACCE), all-cause death, target vessel revascularization (TVR), repeat revascularization (RRV), myocardial infarction (MI), and cerebrovascular events (CVE). The relative risk (RR) was calculated as the summary statistic.

RESULTS

11,452 patients from 22 studies were included, of which 4949 patients underwent OPCAB and 6503 patients received DES. The cumulative rates of MACCE (RR [95% CI]=0.43 [0.34, 0.54], P<0.00001), all-cause death (RR [95% CI]=0.56 [0.33, 0.96], P=0.03), TVR (RR [95% CI]=0.33 [0.21, 0.53], P<0.00001), RRV (RR [95% CI]=0.22 [0.11, 0.42], P<0.00001) and MI (RR [95% CI]=0.13 [0.05, 0.29], P<0.00001) at 3 years were all lower in OPCAB group. The incidences of in-hospital death (RR [95% CI]=1.31 [0.81, 2.13], P=0.27) and MI (RR [95% CI]=1.03 [0.60, 1.78], P=0.92) were not different between groups, but the rate of in-hospital CVE was lower (RR [95% CI]=2.6355 [1.0033, 6.9228], P=0.05) in DES group.

CONCLUSIONS

OPCAB presents better long-term outcomes of MACCE, all-cause mortality, TVR, RRV and MI but uncertain outcome of postoperative CVE without influencing the incidences of in-hospital death and MI.

Early and mid-term results of minimally invasive coronary artery bypass grafting

INTRODUCTION

Minimally invasive coronary artery bypass grafting (MICABG) is a less invasive method of performing surgical revascularization. This technique coupled with use of off pump technique of surgical revascularization makes it truly less invasive. This method is highly effective even in high-risk patients. Results of this procedure are comparable to standard off pump technique and are better than percutaneous coronary intervention utilizing drug-eluting stent. We present an early and mid-term result of the use of this technique.

METHOD

We enrolled 33 patients for analysis operated between 2008 and 2012. Operation was performed utilizing off-pump technique of coronary artery bypass grafting through a minimal invasive incision. Left internal mammary artery graft was done for single vessel disease and radial artery was utilized for other grafts if required. Median follow up of 2.5 years (6 months-4 years) is available.

RESULTS

Median age was 58.5 years (41-77) and all were male. Single vessel disease was present in 7, double vessel in 14 and triple vessel disease in 12 patients. All the patients had normal left ventricular size and function. There was no operative and 30-day mortality. Conversion to median sternotomy to complete the operation was done in 6.6% (2 out of 33 patients). One patient had acute myocardial infarction and there were no deaths during follow up.

CONCLUSION

MICABG is a safe and effective method of revascularization in low risk candidates for coronary artery bypass grafting.

Treatment of left anterior descending coronary artery stenosis: stent or surgery

BACKGROUND

Drug-eluting stents have emerged as a solution to the problem of restenosis after bare-metal stent implantation, as an alternative to off-pump coronary bypass, for isolated left anterior descending coronary artery lesions at short-term follow-up. However, long-term follow-up is yet to be defined.

METHODS

From January to December 2004, 64 consecutive patients underwent myocardial revascularization: 31 by drug-eluting stents and 33 by off-pump coronary bypass. The primary endpoint was angiographic outcome, and the secondary endpoint was clinical outcome at 5 years.

RESULTS

There was no early or late mortality in either group. Hospital stay was significantly shorter in the stent group (2.5 ± 2.1 vs. 7.1 ± 4.9 days, p = 0.003). Long-term patency was higher and major adverse cardiac events (recurrence of angina and revascularization of target vessel) were encountered less frequently in the coronary bypass group, although not significantly.

CONCLUSION

The 5-year follow-up showed no significant difference between the off-pump coronary bypass and stent groups for the primary and secondary endpoints. As a significant difference between treatment options is lacking, decision-making for appropriate treatment in this group of patients requires the collaboration of cardiologists and cardiovascular surgeons and an individual approach, to achieve successful long-term outcomes.

Minimally invasive direct coronary artery bypass improves late survival compared with drug-eluting stents in isolated proximal left anterior descending artery disease: a 10-year follow-up, single-center, propensity score analysis

OBJECTIVES

Minimally invasive direct coronary artery bypass (MIDCAB) has been proposed to reduce surgical morbidity and improve long-term outcomes compared with stenting in the treatment of isolated proximal left anterior descending artery. However, the survival benefit from MIDCAB still needs to be demonstrated, in particular, because percutaneous coronary intervention with drug-eluting stents (DES-PCI) continues to be considered the initial treatment strategy. We conducted a 10-year follow-up, single-center, propensity score-matched MIDCAB versus DES-PCI comparison.

METHODS

A total of 1033 patients (303 MIDCAB and 730 DES-PCI) with isolated proximal left anterior descending disease were included. Propensity score matching was used to compare 303 pairs of MIDCAB and DES-PCI patients.

RESULTS

MIDCAB and DES-PCI presented with comparable 30-day mortality (2 of 303 [0.6%] vs 1 of 303 [0.3%]; P=1.0). At 10 years, DES-PCI was associated with a 2.19-fold increased risk of late death (95% confidence interval, 1.15-4.17), a 2.0-fold increased risk of repeat revascularization (95% confidence interval, 1.20-3.47), and a 2.14-fold increased risk of the composite of death and repeat revascularization (95% confidence interval, 1.41-3.24).

CONCLUSIONS

These findings strongly support a survival benefit from MIDCAB at long-term follow-up compared with DES-PCI in the treatment of isolated left anterior descending disease.

Clinical and angiographic results after hybrid coronary revascularization

BACKGROUND

With hybrid coronary revascularization (HCR), minimally invasive left internal mammary artery (LIMA) to left anterior descending coronary artery (LAD) grafting is combined with percutaneous coronary intervention (PCI) of non-LAD vessels. The purpose of this study was to examine the short-term clinical and angiographic results in one of the largest HCR series to date.

METHODS

From 2003 to 2012, 300 consecutive patients (aged 64±12 years, female 31.7%, predicted risk of mortality 1.6%±2.1%) underwent HCR on an intent-to-treat basis at a single institution. After robotic or thoracoscopic LIMA harvest, off-pump LIMA to LAD grafting was performed through a 3- to 4-cm sternal-sparing, non-rib-spreading thoracotomy. PCI was utilized to treat non-LAD lesions either before, after, or concomitant with the surgical procedure.

RESULTS

Of the 300 patients undergoing HCR on an intent-to-treat basis, HCR was performed with surgery first in 192 patients (64.0%), PCI first in 56 (18.7%), and as a concomitant procedure in 21 (7.0%). Of the 31 patients (10.1%) who did not undergo HCR, 24 patients (8.0%) did not have PCI and thus were incompletely revascularized. For all patients, 30-day mortality, stroke, and nonfatal myocardial infarction occurred in 4 (1.3%), 3 (1.0%), and 4 (1.3%), respectively. Angiographic LIMA evaluation was performed in 248 patients and revealed a FitzGibbon A LIMA patency rate of 97.6% (242 of 248 patients). Repeat revascularization was required in 13 of 300 patients (4.3%).

CONCLUSIONS

Hybrid coronary revascularization represents an alternative approach for patients with multivessel coronary disease with excellent short-term outcomes. It provides a minimally invasive alternative to traditional coronary artery bypass graft surgery and may prove more durable than multivessel PCI.

Minimally invasive direct coronary artery bypass versus off-pump coronary surgery through sternotomy

INTRODUCTION

Although it is not a new technique, minimally invasive direct coronary artery bypass (MIDCAB) is employed only by a few surgeons in the UK. We compared our experience with MIDCAB with that of single vessel off-pump coronary artery bypass (OPCAB) graft surgery through a standard median sternotomy.

METHODS

Patients who underwent either MIDCAB or OPCAB between April 2008 and July 2011 were reviewed. Exclusion criteria included patients with an ejection fraction of <0.5 or previous cardiac surgery. Data were obtained retrospectively from our prospective database, medical records and through general practitioners.

RESULTS

Overall, 74 patients were analysed in the MIDCAB group and 78 in the OPCAB group. Their demographics and EuroSCORE (European System for Cardiac Operative Risk Evaluation) values were comparable (p>0.05). There was no statistically significant difference in the two groups in terms of mortality, recurrent myocardial infarction, postoperative stroke, wound infection, atrial fibrillation or need for reintervention. The MIDCAB group had six conversions to a sternotomy. Eight patients in each group required blood transfusion, with the average transfusion being 1.8 units in the MIDCAB group and 3.2 units in the OPCAB group. The mean duration of ventilation and intensive care unit stay was 5.0 hours and 38.4 hours in the MIDCAB group and 5.4 and 47.8 hours in the OPCAB group. The mean hospital stay was significantly reduced in the MIDCAB population (6.1 vs 8.5 days, p<0.05).

CONCLUSIONS

MIDCAB can be performed safely in appropriately selected patients with outcomes comparable with OPCAB. The potential benefits include shorter hospital stay, reduced need for blood transfusion and faster recovery.

Endoscopic harvesting of the left internal mammary artery

Minimally invasive coronary artery bypass grafting via left anterior small thoracotomy is routinely performed on patients with single coronary artery disease, but recently has been expanded to a larger population as a part of a hybrid treatment in multivessel coronary artery disease. While the methods of internal mammary artery harvesting used in these operations can be different, the endoscopic method is more advantageous than operations performed by direct vision, and thus should be used as a technique of choice. In this article, we present detailed description of endoscopic mammary artery harvesting focusing on anatomical and technical aspects.

Minimally invasive cardiac surgery for atrial fibrillation complicated by coronary artery disease: combination of video-assisted pulmonary vein isolation and minimally invasive direct coronary artery bypass

Here we report a minimally invasive cardiac surgery procedure without sternotomy combining video-assisted bilateral pulmonary vein isolation and minimally invasive direct coronary artery bypass as treatment for atrial fibrillation complicated by coronary artery disease. The patient's chest was accessed through a left anterolateral thoracotomy over the fourth intercostal space, and the left internal thoracic artery (LITA) was harvested under direct vision. The left pulmonary veins were isolated electrically by a bipolar radiofrequency clamp. Subsequently, the harvested LITA graft was anastomosed to the left anterior descending artery. Right pulmonary vein isolation was then performed through a small thoracotomy at the right fourth intercostal region in the same manner as the left side. A linear block on the left atrial roof, connecting the lesions encircling the left and right pulmonary veins, was created from both sides by a pen-like bipolar radiofrequency.

Coronary artery bypass grafting without full sternotomy

Coronary artery bypass grafting is performed without full sternotomy in selected patients because it is less invasive. Left internal thoracic artery-left anterior descending artery bypass (LITA-LAD bypass) via a small left anterior thoracotomy is a well established procedure, which achieves good graft patency with low mortality and morbidity rates. Multiple revascularization is possible with a limited lateral thoracotomy or L-figure approach. Axillary-coronary bypass and right gastroepiploic artery-right coronary artery bypass (RGEA-RCA bypass) are alternative methods, especially for redo surgery, in selected patients.

Percutaneous treatment with drug-eluting stent vs bypass surgery in patients suffering from chronic stable angina with multivessel disease involving significant proximal stenosis in left anterior descending artery

BACKGROUND

The aim of the present study was to compare the effects of drug-eluting stents (DES) and coronary artery bypass grafting (CABG) in patients suffering from chronic stable angina with multivessel disease, involving significant proximal stenosis in the left anterior descending artery (LAD).

METHODS AND RESULTS

All consecutive patients suffering from chronic stable angina with multivessel disease involving significant proximal LAD stenosis underwent DES implantation (n=600) or CABG (n=709) at our institution. At 2 years, the unadjusted mortality was significantly lower in the DES group than in the CABG group (2.2% vs 5.2%, P=0.004), but the adjusted risk of death was similar (odds ratio (OR) 0.74, 95%CI 0.28-1.97, P=0.555). Furthermore, both the adjusted rate of nonfatal myocardial infarction and cerebrovascular events was also comparable. However, the unadjusted and adjusted risk of major adverse cardiac cerebrovascular events in the DES was significantly higher than in the CABG (13.3% vs 9.6%, OR 2.71, 95%CI 1.56-4.74, P<0.001), which is probably attributed to the higher subsequent revascularization rate after DES implantation.

CONCLUSIONS

DES showed comparable long-term mortality for the treatment of multivessel disease involving significant proximal stenosis in LAD in comparison with CABG.

Catheter-based endoscopic bypass grafting: an experimental feasibility study

PURPOSE

Construction of an endoscopic catheter-guided, bonded anastomosis to facilitate total endoscopic coronary artery bypass.

DESCRIPTION

Total endoscopic coronary artery bypass of the left internal thoracic artery to the left anterior descending coronary artery was performed on the beating heart in six pigs using a telemanipulation system. An angioplasty catheter was advanced through the left internal thoracic artery to stabilize the anastomotic site. The anastomosis was created by applying glue externally to the surrounding tissue of the left internal thoracic artery and the left anterior descending coronary artery while it was kept open by an inflated angioplasty catheter.

EVALUATION

Angiography and catheter placement at the graft site was performed in 12 minutes (10 to 28 minutes). The anastomotic constructions were easily accomplished in 3.5 minutes (2 to 4.5 minutes). The adverse events that were encountered were anastomotic leakage requiring additional glue and left anterior descending artery dissection due to the guidewire. All except one animal with an open graft and anastomosis survived the procedure. Patency was 5 of 6.

CONCLUSIONS

Catheter-based endoscopic bypass grafting is feasible. The combination of robotic technology and this simple technique for anastomotic construction may facilitate beating heart total endoscopic coronary artery bypass.