Invited Commentary

Abstract

The optimal treatment of de novo multivessel coronary artery disease (CAD) has become increasingly clear because of the accumulating evidence that strongly supports coronary artery bypass grafting (CABG) over percutaneous intervention (PCI) [1Sipahi I. Akay M.H. Dagdelen S. Blitz A. Alhan C. Coronary artery bypass grafting vs percutaneous coronary intervention and long-term mortality and morbidity in multivessel disease: meta-analysis of randomized clinical trials of the arterial grafting and stenting era.JAMA Intern Med. 2014; 174: 223-230Crossref PubMed Scopus (177) Google Scholar]. This is particularly true for diabetic patients. The large (1,900 diabetic patients) FREEDOM randomized controlled trial (RCT) [2Farkouh M.E. Domanski M. Sleeper L.A. et al.FREEDOM Trial InvestigatorsStrategies for multivessel revascularization in patients with diabetes.N Engl J Med. 2012; 367: 2375-2384Crossref PubMed Scopus (1376) Google Scholar] found superior survival (hazard ratio [HR] = 0.73, p = 0.02), myocardial infarction (MI) (HR = 0.49, p < 0.001), and repeat revascularization (HR = 0.37, p < 0.001) rates for CABG versus PCI with the use of drug-eluting stents (DES). In an effort to confirm these often selective RCTs, Kurlansky and colleagues [3Kurlansky P. Herbert M. Prince S. Mack M.J. Improved long-term survival for diabetic patients with surgical versus interventional revascularization.Ann Thorac Surg. 2015; 99: 1298-1305Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar] have retrospectively compared their real-world outcomes of CABG versus PCI, focusing on diabetic patients in a community-based eight-hospital registry. They studied 1,082 diabetic patients who underwent revascularization over a 6-month period in 2004 and were followed up for an average of 5.5 years. Of the group, 334 patients had CABG (51% on pump with 93% receiving a left internal thoracic artery (LITA) and 5% bilateral internal thoracic artery (BITA) grafting, with an average of 3.2 grafts per patient), and 748 patients had PCI (15% bare metal stents, 75% DES, and 10% balloon angioplasty with an average of 2.2 stents per patient). Propensity matching resulted in 240 matched CABG and PCI pairs. The authors found that CABG decreased mortality (HR = 0.60, p = 0.023) and the need for any revascularization (HR = 0.32, p = 0.003). No difference in MI rates was observed. This CABG mortality benefit persisted when 202 CABG patients were propensity matched with only DES PCI patients. There was again a significant decrease in mortality for CABG patients (HR = 0.58, p = 0.033) but now no differences in rates of both MI and revascularization. The authors conclude that their real-world registry data confirms the mortality benefit observed in RCTs and that their data supports the broad application of CABG over PCI in diabetic patients with extensive CAD. Kurlansky et al [3Kurlansky P. Herbert M. Prince S. Mack M.J. Improved long-term survival for diabetic patients with surgical versus interventional revascularization.Ann Thorac Surg. 2015; 99: 1298-1305Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar] are to be commended for their efforts to better define the optimal treatment of diabetic patients with CAD. The authors found a very clear survival benefit of CABG compared with PCI in diabetic patients. Their study does have several limitations inherent in retrospective analyses, resulting in differing rates of MI and repeated revascularization compared with the findings of the RCTs as just noted. Nonetheless, their contribution further supports the primary role of CABG in diabetic patients. How are these findings best incorporated into the treatment of diabetic patients with multivessel CAD? First, a heart team approach using an evidence-based, guideline-driven decision making process is needed. Cardiac surgeons need to be very involved in the decision making and need to be advocates for patients seeking the safest and most durable treatment. Finally, the choice of conduits and their impact on long=term survival should enter into the decision making. As Kurlansky and his colleagues [3Kurlansky P. Herbert M. Prince S. Mack M.J. Improved long-term survival for diabetic patients with surgical versus interventional revascularization.Ann Thorac Surg. 2015; 99: 1298-1305Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar] correctly observed, their low rate of BITA grafting (5%) likely underestimated the full benefit of CABG over PCI. The use of BITA is, in fact, quite limited in diabetic patients because of the very real concern of sternal wound infections. We [4Hoffman D.M. Dimitrova K.R. Lucido D.J. et al.Optimal conduit for diabetic patients: propensity analysis of radial and right internal thoracic arteries.Ann Thorac Surg. 2014; 98: 30-37Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar] have found that the radial artery (RA) offers similar long-term survival to the right internal thoracic artery (RITA), with fewer sternal wound and respiratory adverse events in diabetic patients. As stent technology continues to improve, cardiac surgeons need to perform more arterial grafting using either the RA or RITA during CABG-LITA to offer all patients, especially those with diabetes, the optimal revascularization therapy. Improved Long-Term Survival for Diabetic Patients With Surgical Versus Interventional RevascularizationThe Annals of Thoracic SurgeryVol. 99Issue 4PreviewDiabetes is increasing at an alarming rate, affecting nearly 8% of the population. Previous studies have demonstrated a potential benefit for surgical over interventional revascularization in diabetics. However, randomized clinical trials comparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) many not accurately reflect current clinical practice. We therefore undertook a prospective registry of coronary revascularization (CR) in diabetic patients with CABG, on-pump and off-pump, and PCI with bare-metal and drug-eluting stents to determine long-term clinical outcomes. Full-Text PDF