Minimally Invasive Direct Coronary Artery Bypass Graft Surgery or Percutaneous Coronary Intervention for Proximal Left Anterior Descending Artery Stenosis: A Meta-Analysis

doi:10.1016/j.athoracsur.2014.01.086

The Annals of Thoracic Surgery

Volume 97, Issue 6, June 2014, Pages 2056-2065

Presented at the Poster Session of the Fiftieth Annual Meeting of The Society of Thoracic Surgeons, Orlando, FL, Jan 25–29, 2014.

https://doi.org/10.1016/j.athoracsur.2014.01.086 Get rights and content

Background

We conducted a metaanalysis comparing early and midterm cardiovascular adverse events associated with minimally invasive direct coronary artery bypass graft surgery (MIDCABG) and percutaneous coronary intervention (PCI), with a focus on drug-eluting stents (DES).

Methods

A systematic literature review (MEDLINE, EMBASE, Scopus, and so forth) yielded 12 studies (7 randomized controlled trials; 5 observational) pooling more than 2,000 patients. A random effect, inverse variance metaanalysis was conducted, and a subgroup analysis of the PCI-DES cohort was performed. Events were compared as risk ratios using a 95% confidence interval (CI). Heterogeneity of results was evaluated by Eggers I² test. Results are presented as early (0 to 1 year) and midterm (2 to 5 years).

Results

Midterm mortality in the PCI and MIDCABG groups (3.6% and 2.6%, respectively) was comparable (1.24, 95% CI: 0.66 to 2.33; p = 0.5; I² = 0%). Risk of early restenosis was lower in the MIDCABG cohort compared with PCI (0.40, 95% CI: 0.16 to 0.99; p = 0.05; I² = 57%). Although the early risk of recurrence of angina was comparable, over time it was 61% (43% to 74%) lower for MIDCABG patients (p < 0.001). Midterm results on analysis of the entire cohort demonstrated an increased risk for target vessel reinterventions (3.84, 95% CI: 2.7 to 5.5; p < 0.001) in the PCI cohort. Subgroup analysis revealed that the PCI-DES cohort (4 studies; 456 patients) had a higher risk of recurrent angina (risk ratio 3.4, 95% CI: 1.9 to 6.2; p < 0.001; I² = 0%) and target vessel reinterventions (risk ratio 4.16, 95% CI: 2.7 to 6.6; p < 0.001; I² = 0%) at midterm follow-up (2 to 5 years).

Conclusions

Survival rates are comparable after either MIDCABG or PCI for proximal LAD disease. However, even the use of DES was associated with significantly higher rates of angina recurrence and the need for target vessel reintervention as compared with MIDCABG.

Section snippets

Inclusion Criteria

Original articles (randomized controlled trials and observational studies) comparing PCI and MIDCABG for p-LAD disease (from 2000 to May 2013) were identified. The search was limited to (1) human subjects, (2) original articles, and (3) English language. Only studies reporting clinically relevant endpoints (eg, mortality, recurrence of angina, or reinterventions during follow-up) were included. Editorials and review articles were excluded.

Technique of MIDCABG

MIDCABG consisted of harvest of the left internal

Results

The initial search criteria yielded 312 articles. Exclusion of duplicates and further refinement of Medical Subject Headings yielded 193 abstracts, which were evaluated for inclusion. The detailed PRISMA flow diagram is presented in Figure 1. Two articles were excluded to avoid patient duplication. A total of 14 articles 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 discussing the results of 12 studies (seven RCTs and five observational studies) fulfilled the selection criteria. Two articles

Comment

Guidelines regarding PCI and CABG in multivessel coronary artery disease are relatively well established. However, limited data are available comparing MIDCABG and PCI for p-LAD disease, especially in the present era of DES. We therefore conducted a pooled analysis of more than 2,000 patients comparing the clinical outcomes in these cohorts.

Our metaanalysis and systematic review of 12 studies (seven RCTs) demonstrate that recurrence of angina and the need for a reintervention is much lower in

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Cited by (19)

Long-term Incidence of Myocardial Infarction and Death After CABG and PCI for Isolated Left Anterior Descending Artery Disease: A Meta-analysis of Randomized Controlled Trials
2023, Journal of the Society for Cardiovascular Angiography and Interventions
To compare the long-term incidence of myocardial infarction (MI) and death in patients randomized to coronary artery bypass grafting (CABG) vs percutaneous coronary intervention (PCI) for treatment of isolated left anterior descending (LAD) coronary artery disease.
We systematically identified all randomized controlled trials comparing PCI with stenting to CABG with a left internal mammary artery (LIMA) graft in patients with isolated LAD disease who had at least 4 years of follow-up. The primary outcome of interest was MI. Secondary outcomes were all-cause mortality and target vessel revascularization (TVR).
Four trials were included in the current analysis, with a total of 573 patients randomized to CABG with a LIMA (n = 285) vs PCI (n = 288) and followed for 4 to 10 years. At latest follow-up (weighted mean 8.3 years), there was no statistically significant difference in the risk of MI between CABG and PCI (relative risk [RR], 1.33; 95% CI, 0.62-2.83; P = .46), nor was there a statistically significant difference in mortality between the groups (RR, 1.04; 95% CI, 0.70-1.65; P = .84). There was a significantly lower risk of TVR after CABG compared with PCI (RR, 0.27; 95% CI, 0.15-0.46; P < .001).
The current meta-analysis suggests that there is insufficient evidence that CABG with a LIMA confers protection against MI or death compared to PCI with a stent for isolated LAD disease. CABG was, however, associated with reduced rates of TVR.
Minimally invasive direct coronary artery bypass (MIDCAB)
2020, Cirugia Cardiovascular
La revascularización coronaria de la arteria descendente anterior (DA) mediante derivación aortocoronaria mínimamente invasiva (MIDCAB) mantiene los beneficios del uso de la arteria mamaria interna izquierda y evita las complicaciones asociadas a la esternotomía media y a la circulación extracorpórea. El objetivo es presentar nuestra experiencia inicial en el MIDCAB.
Se incluyeron todos los pacientes intervenidos mediante MIDCAB de marzo 2019 a junio del 2020. En todos los pacientes se realizó un puente coronario de arteria mamaria interna izquierda a la descendente anterior mediante minitoracotomía anterolateral izquierda sin circulación extracorpórea.
Se intervinieron 22 pacientes. La mediana de edad era de 70 años (IQR 63-77) y el 90,9% (n = 20) eran varones. En dos pacientes con estenosis aórtica severa se realizó simultáneamente implante de una prótesis aórtica transcatéter por vía transapical y en ocho (36,4%) pacientes se realizó un procedimiento híbrido con revascularización percutánea al resto de lesiones. No hubo mortalidad hospitalaria, infarto agudo de miocardio, accidente cerebrovascular, ni fracaso renal agudo postoperatorio. La mediana de estancia hospitalaria fue de cuatro días (IQR 3-5).
El MIDCAB es una técnica segura y eficaz para la revascularización coronaria en el territorio de la descendente anterior que combina las ventajas de un abordaje mínimamente invasivo sin circulación extracorpórea y el uso de la arteria mamaria interna izquierda para la realización de un puente coronario.
Coronary revascularization of the anterior descending artery (DA) using MIDCAB (Minimally Invasive Direct Coronary Artery Bypass) maintains the benefits of the use of the left internal mammary artery (AMII) and avoids the complications associated with middle sternotomy and extracorporeal circulation. The objective is to present our initial experience at MIDCAB.
All patients who underwent MIDCAB from March 2019 to June 2020 were included. In all patients, a left internal mammary artery bypass was performed to the anterior descending artery using a left anterolateral minithoracotomy without extracorporeal circulation.
22 patients. The median age was 70 years (IQR 63-77) and 90.9% (n = 20) were male. Transapical aortic valve implantation was performed simultaneously in two patients with severe aortic stenosis and in 8 (36.4%) patients a hybrid procedure with percutaneous coronay intervention was performed for the rest of the lesions. There were no hospital mortality, miocardial infarction, stroke, or postoperative acute renal failure. The median hospital stay was 4 days (IQR 3-5).
MIDCAB is a safe and effective technique for coronary revascularization in the left anterior descending coronary artery that combines the advantages of a minimally invasive approach without extracorporeal circulation and the use of the left internal mammary artery bypass.
Comparison of Outcomes of Coronary Artery Bypass Grafting Using Internal Mammary Graft Versus Percutaneous Coronary Intervention for Isolated Proximal Left Anterior Descending Narrowing
2017, American Journal of Cardiology
There are limited contemporary studies comparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for isolated proximal left anterior descending (LAD) disease. Increasing stent length and decreasing stent diameters are associated with increased risk of restenosis and adverse outcomes after PCI. Whether these parameters influence outcomes when comparing CABG and PCI is unclear. We compared CABG and PCI in 3,473 patients who underwent revascularization for isolated proximal LAD disease from 2004 to 2015 at Harefield Hospital, UK; 3,078 patients (89%) had PCI and 384 patients had CABG (11%). We analyzed all-cause mortality at 3 years. The unadjusted mortality rates were similar (PCI vs CABG: 9.5% vs 7.0%, p = 0.109). PCI was associated with comparable mortality (hazard ratio [HR] 1.15, 95% confidence interval [CI] 0.70 to 1.89, p = 0.593), even when stratified to bare-metal stents (HR 1.58, 95% CI 0.89 to 2.80, p = 0.121); first-generation drug-eluting stents (FDES; HR 1.16, 95% CI 0.67 to 2.02, p = 0.597); and second-generation DES (SDES; HR 0.98, 95% CI 0.53 to 1.82, p = 0.946). Stent diameters did not influence outcomes, but PCI was associated with higher mortality when stent length ≥30 mm (HR 2.12, 95% CI 1.12 to 4.03, p = 0.022). There was a linear association between stent length and mortality, and for every 1-mm increase in stent length, the 3-year mortality increased by 0.32%. In conclusion, for patients with isolated proximal LAD disease, PCI and CABG were associated with similar mortality. Increasing stent length was progressively associated with worse outcomes with PCI. For longer segments of disease requiring stent lengths ≥30 mm, CABG may be associated with better outcomes.
Meta-Analysis of Percutaneous Coronary Intervention With Drug-Eluting Stent Versus Coronary Artery Bypass Grafting for Isolated Proximal Left Anterior Descending Coronary Disease
2016, American Journal of Cardiology
Citation Excerpt :
Two meta-analyses including the randomized and observational studies comparing PCI-DES versus CABG have previously been performed.3,4 One study concluded that the PCI-DES cohort (5 studies; 456 patients) had a higher risk of recurrent angina (risk ratio 3.4, 95% CI: 1.9 to 6.2; p <0.001) and target vessel re-interventions (risk ratio 4.16, 95% CI: 2.7 to 6.6; p <0.001) at midterm follow-up (2-5 years) compared with minimally invasive direct coronary artery bypass graft surgery.3 The second meta-analysis considered only 2 randomized trials of PCI-DES versus CABG for proximal LAD disease as part of a larger meta-analysis of stents versus CABG but reported that the data were insufficient for any firm conclusions to be made (2 studies; 319 patients).4
We performed a meta-analysis of the studies comparing the efficacy and safety of coronary artery bypass surgery against percutaneous coronary intervention with drug-eluting stents (PCI-DES) in patients with isolated LAD disease. Because of the limited randomized trial data, the optimal revascularization strategy for patients with isolated LAD disease remains uncertain. Using MEDLINE and EMBASE to source data, 11 studies (3 randomized trials and 8 cohort studies) including 5,044 participants were identified. No significant difference in mortality between PCI-DES and coronary artery bypass surgery (CABG; 111 of 2,122 [5.2%] and 120 of 2,574 [4.7%]; relative risk [RR] 1.23; 95% confidence interval [CI] 0.90 to 1.69) was detected. For MACE, PCI-DES was associated with significant increase in adverse events (RR 1.41; 95% CI 1.03 to 1.93, 8 studies, 4,230 participants). There were no significant differences in the risk of myocardial infarction (RR 0.86; 95% CI 0.58 to 1.26) or stroke (RR 2.36; 95% CI 0.54 to 10.43) between the 2 groups. There were 239 target vessel revascularization (TVR) events among 2,237 participants in the PCI-DES group (10.7%) and 145 TVR events among 2,793 participants in the CABG group (5.2%) with a significant increased risk of TVR in the PCI group (RR 2.52; 95% CI 1.69 to 3.77, 5,030 participants) compared with CABG. In conclusion, for patients with isolated disease of the LAD, meta-analysis of the available data suggests revascularization with a PCI-DES strategy offers similar mortality, MI, and stroke rates to CABG at the expense of increased TVR. Much of the data are derived from registries using first-generation DES, and further randomized trials with more contemporary platforms are needed.
Medical Treatment and Revascularization Options in Patients With Type 2 Diabetes and Coronary Disease
2016, Journal of the American College of Cardiology
Citation Excerpt :
Moreover, rates of major adverse cardiovascular events were still higher in a long-term trial among everolimus-treated compared with CABG-treated patients, including augmented rates of MI (34). Clearly, any prospective, contemporary trial will need to incorporate state-of-the-art therapies, but these may not pertain solely to PCI technology but also to CABG, as well as new therapeutic options for medically managing T2DM (36–43). We have already highlighted the limitation of recruiting a sufficient number of patients with low LVEF or pLAD involvement, and all 3 trials excluded subjects with left main CAD.
There are scant outcomes data in patients with type 2 diabetes and stable coronary artery disease (CAD) stratified by detailed angiographic burden of CAD or left ventricular ejection fraction (LVEF).
This study determined the effect of optimal medical therapy (OMT), with or without percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), on long-term outcomes with respect to LVEF and number of diseased vessels, including proximal left anterior descending artery involvement.
A patient-level pooled analysis was undertaken in 3 federally-funded trials. The primary endpoint was the composite of death, myocardial infarction (MI), or stroke, adjusted for trial and randomization strategy.
Among 5,034 subjects, 15% had LVEF <50%, 77% had multivessel CAD, and 28% had proximal left anterior descending artery involvement. During a median 4.5-year follow-up, CABG + OMT was superior to PCI + OMT for the primary endpoint (hazard ratio [HR]: 0.71; 95% confidence interval [CI]: 0.59 to 0.85; p = 0.0002), death (HR: 0.76; 95% CI: 0.60 to 0.96; p = 0.024), and MI (HR: 0.50; 95% CI: 0.38 to 0.67; p = 0.0001), but not stroke (HR: 1.54; 95% CI: 0.96 to 2.48; p = 0.074). CABG + OMT was also superior to OMT alone for prevention of the primary endpoint (HR: 0.79; 95% CI: 0.64 to 0.97; p = 0.022) and MI (HR: 0.55; 95% CI: 0.41 to 0.74; p = 0.0001), and was superior to PCI + OMT for the primary endpoint in patients with 3-vessel CAD (HR: 0.72; 95% CI: 0.58 to 0.89; p = 0.002) and normal LVEF (HR: 0.71; 95% CI: 0.58 to 0.87; p = 0.0012). There were no significant differences in OMT versus PCI + OMT.
CABG + OMT reduced the primary endpoint during long-term follow-up in patients with type 2 diabetes and stable CAD, supporting this as the preferred management strategy.
Revascularization strategy for proximal LAD disease: Left internal mammary to LAD artery still rules the roost
2014, Journal of the American College of Cardiology

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Original articleAdult cardiacMinimally Invasive Direct Coronary Artery Bypass Graft Surgery or Percutaneous Coronary Intervention for Proximal Left Anterior Descending Artery Stenosis: A Meta-Analysis

Background

Methods

Results

Conclusions

Section snippets

Inclusion Criteria

Technique of MIDCABG

Results

Comment

Ann Thorac Surg

J Am Coll Cardiol

Int J Cardiol

Ann Thorac Surg

J Thorac Cardiovasc Surg

Am J Cardiol

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol Intv

Ann Thorac Surg

Ann Thorac Surg

R: a language and environment for statistical computing

Original article
Adult cardiac
Minimally Invasive Direct Coronary Artery Bypass Graft Surgery or Percutaneous Coronary Intervention for Proximal Left Anterior Descending Artery Stenosis: A Meta-Analysis