Percutaneous Coronary Intervention Using Drug-Eluting Stents Versus Coronary Artery Bypass Grafting For Unprotected Left Main Coronary Artery Stenosis: A Meta-Analysis of Randomised Trials

Abstract

Background: Current guidelines suggest that coronary artery bypass grafting (CABG) should be the preferred revascularisation method for unprotected left main coronary artery (ULMCA) stenosis. In light of evidence from recent randomised trials, we assessed whether percutaneous coronary intervention (PCI) using drug-eluting stents (DES) is as safe and effective as CABG for treatment of ULMCA disease. Methods and Results: Digital databases and manual searches were performed for randomised trials comparing PCI and CABG for ULMCA stenosis. Among 3,887 potentially relevant studies, 5 met inclusion criteria. The primary safety endpoint was defined as the composite of all-cause death, myocardial infarction (MI) or stroke. Secondary endpoints included a clinical effectiveness composite, which was defined as all-cause death, MI, stroke or repeat revascularisation. Summary estimates were obtained using random-effect modelling. In total, 4,594 patients were included in the analysis. There was no significant difference in the primary safety endpoint between the revascularisation strategies (OR 0.97, 95%CI 0.79-1.17, p = 0.73). However, when compared with CABG, PCI was less effective (OR 1.36, 95% CI 1.18-1.58, p < 0.001), due to significantly higher rates of repeat revascularisation (OR 1.85, 95%CI 1.53-2.23, p < 0.001). The incidence of all-cause death (OR 1.03, 95%CI 0.78-1.35, p = 0.61), MI (OR 1.46, 95%CI 0.88-2.45, p = 0.08) and stroke (OR 0.88, 95%CI 0.39-1.97, p = 0.53) did not differ between PCI and CABG. Conclusions: PCI using DES and CABG are equally safe methods of revascularisation for patients at low surgical risk with significant ULMCA stenosis. However, CABG is associated with significantly lower rates of repeat revascularisation.