PCI good alternative to CABG in low to intermediate complex CAD

In a meta-analysis published in Journal of American College of Cardiology, the researchers have reported that PCI and CABG show comparable safety in patients with LMCA stenosis and low to intermediate–complexity CAD.

The analysis further goes on to suggest that in patients with significant LMCA stenosis, both PCI with DES and CABG are associated with a comparable risk of all-cause death, MI, or stroke at long-term follow-up. However, the risk of repeat revascularization was higher for PCI at long-term follow-up compared with CABG

Giacoppo D, Colleran R, Cassese S, et al. searched PubMed, Scopus, EMBASE, Web of Knowledge, and ScienceDirect databases from December 18, 2001, to February 1, 2017. They adhered to specified Inclusion criteria which were randomized clinical trial, patients with LMCA stenosis, PCI versus CABG, exclusive use of DES, and clinical follow-up of ≥3 years. Trial-level hazard ratios (HRs) and 95% confidence intervals (CIs) were pooled by fixed-effect and random-effects models with inverse variance weighting. Time-to-event individual patient data for the primary endpoint were reconstructed. Sensitivity analyses according to DES generation and coronary artery disease (CAD) complexity were also performed. The primary endpoint was a composite of all-cause death, myocardial infarction (MI), or stroke at long-term follow-up. Secondary endpoints included repeat revascularization and a composite of all-cause death, MI, stroke, or repeat revascularization at long-term follow-up.

In total of four randomized clinical trials pooled; 4,394 patients with mean age 65.4 years were included in the analysis out of which 3,371 (76.7%) were men; pooled. According to Grading of Recommendations, Assessment, Development and Evaluation, evidence quality with respect to the primary composite endpoint was high. PCI and CABG were associated with a comparable risk of all-cause death, MI, or stroke both by fixed-effect (hazard ratio [HR], 1.06; 95% confidence interval [CI], 0.90-1.24; p = 0.48) and random-effects (HR, 1.06; 95% CI, 0.85-1.32; p = 0.60) analysis. Sensitivity analyses according to low to intermediate SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) score (random-effects: HR, 1.02; 95% CI, 0.74-1.41; p = 0.89) and DES generation (first generation: HR, 0.90; 95% CI, 0.68-1.20; p = 0.49; second generation: HR, 1.19; 95% CI, 0.82-1.73; p = 0.36) were consistent. Kaplan-Meier curve reconstruction did not show significant variations over time between the techniques, with a 5-year incidence of all-cause death, MI, or stroke of 18.3% (319 events) in patients treated with PCI and 16.9% (292 events) in patients treated with CABG. However, repeat revascularization after PCI was increased (HR, 1.70; 95% CI, 1.42-2.05; p < 0.001). Other individual secondary endpoints did not differ significantly between groups. Finally, pooled estimates of trials with LMCA stenosis tended overall to differ significantly from those of trials with multivessel CAD without LMCA stenosis.

The authors concluded that PCI and CABG show comparable safety in patients with LMCA stenosis and low to intermediate–complexity CAD.The outcome of analysis was that both PCI and CABG may be reasonable approaches to revascularization in patients with significant LMCA stenosis and predominantly low to intermediate CAD complexity. It shall be worthwhile to leave it to the choice and preference of the patient after explaining them the advantages and shortcomings of both the procedures. However it shall be ideal if the findings of this study are preferably confirmed by an adequately powered randomized trial.

For further reading log on to

Percutaneous Coronary Intervention vs Coronary Artery Bypass Grafting in Patients With Left Main Coronary Artery Stenosis: A Systematic Review and Meta-Analysis. JAMA Cardiol 2017;Sep 13:[Epub ahead of print]