Five-year outcomes following PCI with DES versus CABG for unprotected LM coronary lesions: meta-analysis and meta-regression of 2914 patients

Michel Pompeu Barros De Oliveira Sá,Paulo Ernando Ferraz,Frederico Pires Vasconcelos,Eliobas De Oliveira Nunes,Ricardo Carvalho Lima,Frederico B C De Araújo E Sá Sá,Alexandre Magno Macário Nunes Soares,Rodrigo Renda Escobar

doi:10.5935/1678-9741.20130013

Michel Pompeu Barros De Oliveira Sá, Paulo Ernando Ferraz + Show 6 more

Open Access

https://doi.org/10.5935/1678-9741.20130013

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Journal: Revista Brasileira de Cirurgia Cardiovascular	Publication Date: Jan 1, 2013
Citations: 29	License type: cc-by

Abstract

To compare the safety and efficacy at long-term follow-up of coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) using drug-eluting stents (DES) in patients with unprotected left main coronary artery (ULMCA) disease. MEDLINE, EMBASE, CENTRAL/CCTR, SciELO, LILACS, Google Scholar and reference lists of relevant articles were searched for clinical studies that reported outcomes at 5-year follow-up after PCI with DES and CABG for the treatment of ULMCA stenosis. Five studies (1 randomized controlled trial and 4 observational studies) were identified and included a total of 2914 patients (1300 for CABG and 1614 for PCI with DES). At 5-year follow-up, there was no significant difference between the CABG and PCI-DES groups in the risk for death (odds ratio [OR] 1.159, P=0.168 for random effect) or the composite endpoint of death, myocardial infarction, or stroke (OR 1.214, P=0.083). The risk for target vessel revascularization (TVR) was significantly lower in the CABG group compared to the PCI-DES group (OR 0.212, P<0.001). The risk of major adverse cardiac and cerebrovascular events (MACCE) was significantly lower in the CABG group compared to the PCI-DES group (OR 0.526, P<0.001). It was observed no publication bias about outcomes and considerably heterogeneity effect about MACCE. CABG surgery remains the best option of treatment for patients with ULMCA disease, with less need of TVR and MACCE rates at long-term follow-up.

Highlights

Rationale Current guidelines recommend percutaneous coronary intervention (PCI) of unprotected left main coronary artery (ULMCA) with stents as a Class IIa or IIb alternative to coronary artery bypass graft (CABG) in patients with conditions that are associated with a low risk of PCI procedural complications and/or increased risk of adverse surgical outcomes [1]
Considerations About this Meta-Analysis To our knowledge, this is the first meta-analysis of studies with 5-years follow-up performed to date about PCI-drug-eluting stents (DES) versus CABG in ULMCA disease, providing incremental value by demonstrating that CABG reduces the incidence of target vessel revascularization (TVR) and MACCE compared with PCIDES
As we can see by meta-analysis and meta-regression, the total population of patients with ULMCA disease benefit from surgery and the population of diabetics benefit more, since the presence of diabetes modulate the effect toward the protective effect

Summary

Introduction

Rationale Current guidelines recommend percutaneous coronary intervention (PCI) of unprotected left main coronary artery (ULMCA) with stents as a Class IIa or IIb alternative to coronary artery bypass graft (CABG) in patients with conditions that are associated with a low risk of PCI procedural complications and/or increased risk of adverse surgical outcomes [1]. Capodanno et al [2] recently published a meta-analysis of 4 randomized controlled trials and suggested, boldly, that “based on that study, revision of the guidelines regarding left main PCI is warranted, raising the level of evidence of current recommendations from B to A”. Sá et al [5] published a new meta-analysis with 16 studies (three randomized and 13 observational) with 1-year follow up results This one argued against the “non-inferiority” of PCI with DES in comparison to CABG surgery and against the idea that PCI could be considered a reasonable choice in elective cases (not mentioning prohibitive risk patients, acute patients and those who reject surgery), given that, the rates of death between both strategies were not statistically different, the need of new procedures and major adverse cardiac and cerebrovascular events rates were clearly lower in patients treated with CABG surgery. Sá et al [5] emphasized that the length of follow-up considered for their study may have been too short (1-year) to truly detect differences between the treatment groups, and so was the study of published by Capodanno et al [2]

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