Comparison of Off-pump Coronary Artery Bypass Grafting With Percutaneous Coronary Intervention Versus Drug-Eluting Stents for Three-Vessel Coronary Artery Disease

Clinical outcomes of different revascularization approaches for patients with multi-vessel coronary artery disease: A network meta-analysis

BACKGROUND

As surgical techniques continue to evolve, the optimal approach for revascularizing multi-vessel coronary artery disease (CAD) remains a matter of ongoing debate. Accordingly, our objective was to compare and contrast various surgical techniques utilized in the management of multi-vessel CAD.

METHODS

A systematic literature review was performed using PubMed, Embase, and Cochrane central register of controlled trials from inception to May 2022. Random-effects network meta-analysis was performed for the primary outcome; target vessel revascularization (TVR), and secondary outcomes; mortality, major adverse cardiac and cerebrovascular events, postoperative myocardial infarction, new-onset atrial fibrillation, stroke, new-onset dialysis, in patients undergoing percutaneous coronary intervention (PCI) with a stent, off-pump coronary bypass graft, on-pump coronary artery bypass graft (ONCABG), hybrid coronary revascularization, minimally-invasive coronary artery bypass, or robot-assisted coronary artery bypass (RCAB) surgeries.

RESULTS

A total of 8841 patients were included from 23 studies. The analysis showed that ONCABG had the highest freedom from TVR, with a mean (SD) absolute risk of 0.027 (0.029); although ONCABG was found to be superior to all other methods, it was only significantly better than first-generation stent PCI. While RCAB did not demonstrate significant superiority over other treatments, it showed a greater probability of preventing postoperative complications. Notably, no significant heterogeneity was calculated for any of the reported outcomes.

CONCLUSIONS

ONCABG shows a better rank probability compared to all other techniques for preventing TVR, while RCAB offers greater freedom from most postoperative complications. However, given the absence of randomized controlled trials, these results should be interpreted with caution.

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.

Clinical Outcomes of Revascularization Strategies for Patients With MVD/LMCA Disease: A Systematic Review and Network Meta-Analysis

Hybrid coronary revascularization (HCR), a new minimally invasive procedure for patients requiring revascularization for multivessel coronary lesions, combines coronary artery bypass grafting (CABG) for left anterior descending (LAD) lesions and percutaneous coronary intervention (PCI) for non-LAD coronary lesions. However, available data related to outcomes comparing the 3 revascularization therapies is limited to small studies.We conducted a search in MEDLINE, EMBASE, and the Cochrane Library of Controlled Trials up to December 31, 2014, without language restriction. A total of 16 randomized trials (n=4858 patients) comparing HCR versus PCI or off-pump CABG (OPCAB) were included in this meta-analysis. The primary outcomes were major adverse cardiac and cerebrovascular events (MACCE), all-cause death, myocardial infarction (MI), cerebrovascular events (CVE), and target vessel revascularization (TVR). Odds ratios (OR) and 95% confidence intervals (CI) were calculated using random-effect and fixed-effect models. Ranking probabilities were used to calculate a summary numerical value: the surface under the cumulative ranking (SUCRA) curve.No significant differences were seen between the HCR and PCI in short term (in hospital and 30 days) with regard to MACCE (odds ratio [OR] = 0.51, 95% confidence interval [CI] 0.00-2.35), all-cause death (OR = 2.09, 95% CI 0.34-7.66), MI (OR = 1.02, 95% CI 0.19-2.95), CVE (OR = 4.45, 95% CI 0.39-19.16), and TVR (OR = 6.99, 95% CI 0.17-39.39). However, OPCAB had lower MACCE than HCR (OR = 0.19, 95% CI 0.00-0.95). In midterm (1 year and 3 year), in comparison with HCR, PCI had higher all-cause death (OR = 5.66, 95% CI 0.00-13.88) and CVE (OR = 4.40, 95% CI 0.01-5.68), and lower MI (OR = 0.51, 95% CI 0.00-2.86), TVR (OR = 0.53, 95% CI 0.05-2.26), and thus the MACCE (OR = 0.51, 95% CI 0.00-2.35). Off-pump CABG presented a better outcome than HCR with significant lower MACCE (OR = 0.17, 95% CI 0.01-0.68). Surface under the cumulative ranking probabilities showed that HCR may be the superior strategy for MVD and LMCA disease when regarded to MACCE (SUCRA = 0.84), MI (SUCRA = 0.76) in short term, and regarded to MACCE (SUCRA = 0.99), MI (SUCRA = 0.94), and CVE (SUCRA = 0.92) in midterm.Hybrid coronary revascularization seemed to be a feasible and acceptable option for treatment of LMCA disease and MVD. More powerful evidences are required to precisely evaluate risks and benefits of the 3 therapies for patients who have different clinical characteristics.

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.

Anaortic, total-arterial, off-pump coronary artery bypass surgery: why bother?

Coronary artery bypass grafting (CABG) remains the standard of care for multi-vessel coronary disease. However, the increased rate of peri-operative stroke reported after surgery compared to percutaneous coronary intervention (PCI) remains of concern. Anaortic, total-arterial, off-pump coronary artery bypass (OPCAB) grafting is a technique that offers the main advantages of surgical revascularisation with a rate of stroke that is equivalent to that of PCI. Some recent trials comparing conventional on-pump CABG with OPCAB have questioned the efficacy of the off-pump technique - these are most often performed with manipulation of the ascending aorta. We review the potential benefits of the anaortic, total-arterial OPCAB technique to explain why it is being employed by an increasing number of surgeons.

Comparison of long-term outcome of off-pump coronary artery bypass grafting versus drug-eluting stents in triple-vessel coronary artery disease

After the introduction of drug-eluting stents (DESs), percutaneous coronary intervention with DESs has challenged coronary artery bypass grafting as the gold standard for the treatment of 3-vessel coronary artery disease. The purpose of this study was to compare the long-term clinical results between percutaneous coronary intervention with DESs and off-pump coronary artery bypass grafting (OPCAB) in 3-vessel coronary artery disease. Two hundred ninety propensity-score matched patients with 3-vessel coronary artery disease treated by DESs or OPCAB were included. Mean follow-up duration was 58.8 ± 11.5 months (2 to 73) and follow-up rate was 97.9%. Five-year survival rates were 94.8 ± 2.1% in the DES group and 96.5 ± 1.5% in the OPCAB group (p = 0.658). Five-year rates of freedom from major adverse cardiac and cerebrovascular event were 71.6 ± 4.1% in the DES group and 89.6 ± 2.5% in the OPCAB group (p < 0.001). Freedom from nonfatal myocardial infarction and target vessel revascularization rates were the determining factors between the 2 groups (p = 0.018 and p < 0.001, respectively). The OPCAB group showed better clinical outcomes compared to the DES group in 3-vessel coronary artery disease after 5-year follow-up. Freedom from major adverse cardiac and cerebrovascular event rate was significantly higher in the OPCAB group mainly because of the lower incidence of target vessel revascularization and nonfatal myocardial infarction. Longer follow-up with randomization will clarify our present conclusions.

Off-pump coronary artery bypass vs percutaneous coronary intervention. Therapeutic strategies for 3-vessel coronary artery disease: OPCAB vs PCI(PCI-Side)

Coronary artery bypass graft (CABG) surgery is still the best therapy for patients with multivessel and left main coronary artery disease. Recently, the introduction of percutaneous coronary intervention (PCI) with drug-eluting stents (DES) in these patients has improved the restenosis rate compared with bare metal stents. Furthermore, according to the results of the SYNTAX trial, no differences were found in the frequencies of mortality or myocardial infarction between CABG and PCI patients. PCI with DES is being increasingly performed for the treatment of patients with either left main trunk, diffuse, or multivessel lesions. In Japan, to avoid any side effects from cardiopulmonary bypass, off-pump coronary artery bypass (OPCAB) was performed in 66% of the total isolated CABG procedures in 2009, and is markedly different from the procedures performed in North America and Europe. However, the comparative effectiveness of PCI and OPCAB remains uncertain. In the present study, the current evidence from randomized trials, a meta-analysis and several observation studies are reviewed.

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.