J-SAP Study 1-2: Outcomes of Patients With Stable High-Risk Coronary Artery Disease Receiving Medical-Preceding Therapy in Japan A Comparison With CABG-Preceding Therapy

A meta-analysis of randomized control trials comparing minimally invasive direct coronary bypass grafting versus percutaneous coronary intervention for stenosis of the proximal left anterior descending artery

Percutaneous intervention (PCI) and minimally invasive direct coronary bypass grafting (MIDCAB) are both well-accepted treatment options for isolated high-grade stenosis of proximal left anterior descending coronary artery. Small studies comparing the two modalities have yielded conflicting results. We performed a meta-analysis of randomized control trials to compare percutaneous intervention with minimally invasive coronary bypass grafting for isolated proximal left anterior descending artery stenosis. Five randomized trials with a total of 711 patients and average follow-up of 2.3 years were included in the analysis; 380 patients received stents and 331 underwent surgery. Only one trial used drug eluting stents. There were a small number of events overall in each trial. Difference between mortality was 12 events versus 15 between the PCI versus MIDCAB group. Similarly, the difference in myocardial infarction was 14 versus 10, and target vessel revascularization was 56 versus 19. The relative risk for stenting versus MIDCAB was 0.96 [(95% CI: 0.47, 1.99), p=0.92, I(2)=17.5%], for mortality and myocardial infarction, 0.77 [(95% CI: 0.30, 2.01), p=0.60, I(2)=10.4%] for mortality and 1.81 [(95% CI: 0.80, 4.06), p=0.15, I(2)=65.9%] for the composite end point of mortality, myocardial infarction and target vessel revascularization. Excluding the trial with drug eluting stents the relative risk for the composite outcome of mortality, myocardial infarction and target vessel revascularization was significantly higher for PCI [RR=2.27 (95% CI: 1.32, 3.90), p=0.003, I(2)=18.9%]. Overall mortality and myocardial infarction rates are similar for bare metal stents versus MIDCAB, but surgery was associated with significantly lower rates of repeat revascularization. The number of randomized patients and events were small. The effect of drug eluting stents might close the gap of repeat revascularization compared to MIDCAB for this disease.

Feasibility and Safety of Transradial Stenting for Unprotected Left Main Coronary Artery Stenoses

BACKGROUND

Percutaneous coronary intervention (PCI) is considered an excellent alternative treatment for unprotected left main coronary artery (ULMCA) stenoses. Most PCIs for ULMCA stenoses are performed via the transfemoral approach. The feasibility and safety of the transradial approach for this particular entity are unknown. The present study assessed the feasibility, safety and 1-year outcomes of the transradial approach for stenting of ULMCA stenoses.

METHODS AND RESULTS

Of 131 consecutive patients who underwent coronary stenting for ULMCA stenoses, 113 patients (86.3%) received stenting using the transradial approach. All 113 procedures were performed with 6 or 7 French (Fr) catheters except 1 procedure requiring an 8 Fr guiding catheter for directional atherectomy. The technical success rate was 100%, and angiographic success was achieved in 96 patients (85.9%). Two patients had local hematoma (1.8%), and no procedure-related deaths, Q-wave myocardial infarction, repetitive PCI, stroke or emergent coronary artery bypass graft surgery during hospitalization were noted. One (0.9%) in-hospital cardiac death occurred due to ventricular tachyarrhythmia. More than half of our patients stayed in hospital by < or =3 days. The 1-year target lesion revascularization and cardiac death rate were 14.2% and 3.5%, respectively.

CONCLUSIONS

This investigation demonstrated the feasibility, safety and accepted short-term clinical outcomes of transradial stenting for ULMCA stenosis. This procedure may offer a feasible alternative to the transfemoral approach.