Mid-to-long term mortality following surgical versus percutaneous coronary revascularization stratified according to stent subtype: An analysis of 6,682 patients with multivessel disease.

Shahzad G Raja,Rebecca Lane,Tito Kabir,Richard Grocott-Mason,Mark Mason,Fabio De Robertis,Andre Simon,Charles Ilsley,Aron Popov,Miles C Dalby,Toufan Bahrami,M Bilal Iqbal,Robert D Smith,Chiara Lazzeri

doi:10.1371/journal.pone.0191554

Abstract

BackgroundStudies comparing coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) have largely been performed in the bare-metal stent (BMS) and first-generation drug eluting stent (F-DES) era. Second-generation DES (S-DES) have shown improved outcomes when compared to F-DES, but data comparing CABG with PCI using S-DES is limited. We compared mortality following CABG versus PCI for patients with multivessel disease and analyzed different stent types.MethodsA total of 6,682 patients underwent multivessel revascularization at Harefield Hospital, UK. We stratified CABG patients into single arterial graft (SAG) or multiple arterial grafts (MAG); and PCI patients into BMS, F-DES or S-DES groups. We analyzed all-cause mortality at 5 years.Results4,388 patients had CABG (n[SAG] = 3,358; n[MAG] = 1,030) and 2,294 patients had PCI (n[BMS] = 416; n[F-DES] = 752; n[S-DES] = 1,126). PCI had higher 5-year mortality with BMS (HR = 2.27, 95% CI:1.70–3.05, p<0.001); F-DES (HR = 1.52, 95% CI:1.14–2.01, p = 0.003); and S-DES (HR = 1.84, 95% CI:1.42–2.38, p<0.001). This was confirmed in inverse probability treatment weighted analyses. When adjusting for both measured and unmeasured factors using instrumental variable analyses, PCI had higher 5-year mortality with BMS (Δ = 15.5, 95% CI:3.6,27.5, p = 0.011) and FDES (Δ = 16.5, 95% CI:6.6,26.4, p<0.001), but had comparable mortality with CABG for PCI with SDES (Δ = 0.9, 95% CI: -9.6,7.9, p = 0.844), and when exclusively compared to CABG patients with SAG (Δ = 0.4, 95% CI: -8.0,8.7, p = 0.931) or MAG (Δ = 4.6, 95% CI: -0.4,9.6, p = 0.931).ConclusionsIn this real-world analysis, when adjusting for measured and unmeasured confounding, PCI with SDES had comparable 5-year mortality when compared to CABG. This warrants evaluation in adequately-powered randomized controlled trials.

Highlights

Coronary artery bypass grafting (CABG) and percutaneous coronary intervention are established treatment options for patients with multivessel coronary disease
When examining 5-year mortality, stratified analyses found that percutaneous coronary intervention (PCI) with bare-metal stent (BMS), first-generation drug eluting stent (F-drug-eluting stents (DES)) and Second-generation DES (S-DES) was associated with higher mortality when comparing to all coronary artery bypass graft (CABG), CABG (SAG) and CABG (MAG)
The results of this study have shown that when using standard adjustment and propensity score methods to address measured confounders, PCI was associated with worse outcomes even when stratified to BMS, F-DES and S-DES and compared to CABG with single arterial graft (SAG) and multiple arterial grafts (MAG)

Summary

Background

Studies comparing coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) have largely been performed in the bare-metal stent (BMS) and first-generation drug eluting stent (F-DES) era. Second-generation DES (S-DES) have shown improved outcomes when compared to F-DES, but data comparing CABG with PCI using S-DES is limited. We compared mortality following CABG versus PCI for patients with multivessel disease and analyzed different stent types

Methods

Introduction

Findings

Discussion