Comparison between Multivessel Stenting with Drug Eluting to the LAD and Bilateral Internal Thoracic Artery Grafting
Background. Reduction of restenosis and reinterventions was reported with drug-eluting stents (Cypher). This study compares results of multivessel Cypher stenting with bilateral internal thoracic artery (BITA) grafting.
Methods. From January 2002 to June 2004, 725 consecutive patients underwent multivessel myocardial revasculariza-tion, 95 by 2 or more Cypher stents and 630 by BITA. After matching for age, sex, and extent of coronary artery disease, 2 groups (87 patients each) were used to compare the 2 revas-cularization modalities.
Results. The 2 groups were similar; however, left main and the use of an intra-aortic balloon pump were more prevalent in the BITA group. The number of coronary vessels treated per patient was higher in the BITA group (2.71 versus 2.24 for BITA and Cypher, respectively; P = .001). Mean follow-up was 12 months. Thirty-day mortality was 0 in both groups. There were no late deaths in the BITA group and 2 (2.3%) in the Cypher group (P value was not significant). Angina returned in 29.9% of the Cypher group and 12.6% of the BITA group (P = .005). Multivariable Cox analysis revealed percutaneous intervention (PCI) (Cypher group) to be the only independent predictor of angina recurrence (Odds Ratio 2.62, 95% Confidence Interval 1.11-6.17). There were 10 reinterventions (PCI) in the Cypher group compared to 5 in the BITA group. One-year reintervention-free survival (Kaplan-Meier) of the BITA group was 96% compared to 88% in the Cypher group (P = .015).
Conclusions. Midterm clinical outcome of surgically treated patients is still better. However, the reintervention gap between surgery and percutaneous interventions was reduced by treating 2 or more coronary vessels with Cypher stents.
McFadden EP, Stabile E, Regar E, et al. 2004. Late thrombosis in drug-eluting coronary stents after discontinuation of antiplatelet therapy. Lancet 364:1519-21.nMorice MC, Serruys PW, Sousa E, et al. 2003. RAVEL Study Group. A randomized comparison of a sirolimus-eluting stent with a standard stent for coronary revascularization. N Engl J Med 346:1173-80.nMoses JW, Leon MB, Popma JJ, et al, for SIRIUS Investigators. 2003. Sirolimus-eluting stents versus standard stents in patients with stenosis in native coronary artery. N Engl J Med 349:1315-23.nOlivari Z, Rubartelli P, Piscione F, et al. 2003. Immediate results and one-year clinical outcome after percutaneous coronary interventions in chronic total occlusions: data from a multicenter, prospective, observational study (TOAST-GISE). J Am Coll Cardiol 41:1672-8.nBarner HB, Swartz MI, Mudd JG, Tyras DH. 1982. Late patency of the internal mammary artery as a coronary artery bypass conduit. Ann Thorac Surg 34:408-12.nBuxton BF, Komeda M, Fuller JA, Gordon I. 1998. Bilateral internal thoracic artery grafting may improve outcome of coronary artery surgery. Risk-adjusted survival. Circulation 98(Suppl):III-6.nColonbo A, Mikhail GW, Michev I, et al. 2005. Treating chronic total occlusions using subintimal tracking and reentry: the STAR technique. Catheter Cardiovasc Interv 64:407-11.nSawhney N, Moses JW, Leon MB, et al. 2004. Treatment of left anterior descending coronary artery disease with sirolimus-eluting stents. Circulation 110:374-9. Serruys PW, Unger F, Sousa JE, et al, for the Arterial RevascularizationnTherapies Study Group. 2001. Comparison of coronary artery bypass surgery and stenting for the treatment of multivessel disease. N Engl J Med 344:1117-24.nShirai K, Lansky AJ, Mehran R, et al. 2004. Minimally invasive coronary artery bypass grafting versus stenting for patients with proximal left anterior descending coronary artery disease. Am J Cardiol 93:959-62.nRodriguez A, Rodriguez AM, Baldi J, et al. 2003. Coronary stenting versus coronary bypass surgery in patients with multivessel disease and significant proximal LAD stenosis: results from the ERACI II study. Heart 89:184-8.nGurevitch, J, Miller HI, Shapira I, et al. 1997. High-dose isosorbide dinitrate for myocardial revascularization with composite arterial grafts. Ann Thorac Surg 63:382-7.nHerz I, Moshkovitz Y, Hendler A, et al. 2005. Revascularization of left anterior descending artery with drug-eluting stents: comparison with off-pump surgery. Ann Thorac Surg 79:88-92.nLev-Ran O, Mohr R, Uretzky G, et al. 2003. Graft of choice to right coronary system in left-sided bilateral internal thoracic artery grafting. Ann Thorac Surg 75:88-92.nLoop DF, Lytle BW, Cosgrove DM, et al. 1986. Influence of internal-mammary-artery-graft on 10 year survival and other cardiac events. N Engl J Med 314:1-6.nLytle BW, Blackstone EH, Loop FD, et al. 1999. Two internal thoracic artery grafts are better than one. J Thorac Cardiovasc Surg 117:885-92.nSilber S, Albertsson P, Aviles FF, et al, for the Task Force for Percutaneous Coronary Intervention of the European Society of Cardiology. 2005. Guidelines for percutaneous coronary interventions. Eur Heart J 26:804-47.nSOS Investigators. 2002. Coronary artery bypass surgery versus percutaneous coronary intervention (PCI) with stent implantation in patients with multivessel coronary artery disease (the stent or surgery trial): a randomized, controlled trial. Lancet 360:961-2.nTanabe K, Hoye A, Lemos PA, et al. 2004. Restenosis rate following bifurcation stenting with sirolimus-eluting stents for de novo narrowings. Am J Cardiol 94:115-8.nVimani R, Farb A, Guagliumi G, Kolodgie FD. 2004. Drug-eluting stents: caution and concerns for long-term outcome. Coronary Artery Dis 15:313-8.n