Coronary angioplasty versus left internal mammary artery grafting for isolated proximal left anterior descending artery stenosis

doi:10.1016/S0140-6736(94)92579-8

The Lancet

Volume 343, Issue 8911, 11 June 1994, Pages 1449-1453

https://doi.org/10.1016/S0140-6736(94)92579-8 Get rights and content

Abstract

Summary

Coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA) are more effective than medical treatment for the management of ischaemic heart disease. However, patients with single-vessel involvement have been excluded from prospective comparisons of the two methods. We have carried out such a comparison in patients with isolated proximal left anterior descending artery stenosis, conserved left ventricular function, and documented ischaemia.

Eligible patients presenting to a single centre were randomly assigned PTCA (68 patients) or left internal mammary grafting (66). The procedures were technically feasible in all cases. The incidence of in-hospital complications was 2% (perioperative myocardial infarction) for CABG and 3% (emergency CABG for acute closure) for PTCA. Clinical and functional status improved similarly in both groups. However, patients in the PTCA group took more antianginal drugs. At median follow-up of 2·5 years, 86% of CABG-treated and 43% of PTCA-treated patients were free from adverse events (p<0·01; relative risk 2·0 [95% Cl 1·7-2·3]). The adverse events that explain this difference were restenosis (32%) requiring subsequent surgical (16%) or percutaneous (15%) revascularisation (1% had medical therapy). Rates of cardiac death and myocardial infarction did not differ between the groups.

Both CABG and PTCA improve the clinical status of symptomatic patients with single-vessel coronary artery disease. If patient and physician accept the risk of restenosis and reintervention associated with PTCA, this procedure remains a suitable option and a simpler initial alternative to CABG.

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Cited by (146)

Revascularization for Isolated Proximal Left Anterior Descending Artery Disease
2021, Annals of Thoracic Surgery
Most studies of patients with isolated proximal left anterior descending (PLAD) coronary artery disease do not include all 3 procedural options: percutaneous coronary intervention (PCI), conventional coronary artery bypass graft (CABG) surgery, or minimally invasive CABG.
New York’s cardiac registries were used to identify patients who underwent revascularization for isolated PLAD disease between January 1, 2010, and November 30, 2016, in New York State. After exclusions, 14,327 patients, of whom 13,115 received PCI, 1001 of whom underwent CABG surgery, and 211 of whom underwent minimally invasive CABG were monitored through the end of 2017 to compare outcomes. Registry data were matched to vital statistics data to obtain deaths occurring after discharge and matched to claims data to obtain subsequent admissions for myocardial infarction and stroke.
There were no significant differences in mortality or in mortality/myocardial infarction/stroke after 7 years (with median follow-up times in excess of 4 years) among the 3 procedures after adjusting for differences in patient risk factors. However, conventional CABG surgery was associated with a lower subsequent revascularization rate than PCI (adjusted hazard ratio, 0.45; 95% confidence interval, 0.35-0.58) and minimally invasive CABG surgery (adjusted hazard ratio, 0.46; 95% confidence interval, 0.32-0.66).
Among patients with isolated PLAD disease undergoing any of 3 revascularization options (PCI, conventional CABG surgery, or minimally invasive CABG surgery), conventional CABG surgery was associated with lower subsequent revascularization rates, but there were no differences in mortality or mortality/myocardial infarction/stroke rates.
Percutaneous coronary invervention versus coronary artery bypass grafting: A meta-Analysis
2015, Journal of Thoracic and Cardiovascular Surgery
To compare the effectiveness of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with coronary artery disease.
MEDLINE, Embase, and Cochrane Central were searched, and randomized controlled trials were included. Outcomes were assessed at maximum available follow-up.
This meta-analysis includes 31 trials with 15,004 patients. As regards death, more patients died after PCI compared with CABG across all types of patients (odds ratio [OR], 1.1; 95% confidence interval [CI], 1.0-1.3; P = .05) as well as in patients with multivessel disease (OR, 1.2; 95% CI, 1.0-1.4; P = .02) or diabetes (OR, 1.6; 95% CI, 1.2-2.1; P < .01). Myocardial infarction occurred as frequently after PCI (OR, 1.2; 95% CI, 0.9-1.5; P = .28). Repeat revascularization was more common after PCI (OR, 4.5; 95% CI, 3.5-5.8; P < .01), with a progressive decline in ORs from the pre-stent era (OR, 7.0; 95% CI, 5.1-9.7; P < .01), to the bare metal stent era (OR, 4.5; 95% CI, 3.6-5.5; P < .01), and to the drug-eluting stent era (OR, 2.5; 95% CI, 1.8-3.4; P < .01). Stroke was more common after CABG (OR, 0.7; 95% CI, 0.5-0.9; P = .01).
Compared with PCI, CABG had a lower risk of death in multivessel disease or diabetes patients eligible for either intervention, a lower risk of repeat revascularization, but a higher risk of stroke.
Coronary artery bypass graft surgery versus drug-eluting stents for patients with isolated proximal left anterior descending disease
2014, Journal of the American College of Cardiology
Citation Excerpt :
However, the second part of the AUC in this document, which discusses the preferred method when revascularization is indicated, does not rate CABG surgery versus PCI for patients with single-vessel PLAD disease (41). As noted earlier, a total of 17 studies from 9 RCTs examined relative outcomes for CABG surgery and PCI in patients with isolated PLAD disease (16–32). A meta-analysis of these studies by Kapoor et al. (48) found no differences in survival at 30 days, 1 year, or 5 years in patients treated with CABG surgery versus patients treated with PCI.
Few recent studies have compared the outcomes of coronary artery bypass graft (CABG) surgery with percutaneous coronary interventions (PCIs) in patients with isolated (single vessel) proximal left anterior descending (PLAD) coronary artery disease in the era of drug-eluting stents (DES).
The goal of this study was to compare outcomes in patients with PLAD who underwent CABG and PCI with DES.
New York’s Percutaneous Coronary Interventions Reporting System was used to identify and track all patients who underwent CABG surgery and received DES for isolated PLAD disease between January 1, 2008 and December 31, 2010, and who were followed-up through December 31, 2011. A total of 5,340 of 6,064 (88%) patients received DES. Patients were matched to vital statistics data to obtain mortality after discharge and matched to New York’s administrative data to obtain readmissions for myocardial infarction (MI) and stroke. To minimize selection bias, patients were propensity matched into 715 CABG and/or DES pairs, and 3 outcome measures were compared across the pairs.
Kaplan-Meier estimates for CABG and DES did not significantly differ for mortality or mortality, MI, and/or stroke, but repeat revascularization rates were lower for CABG (7.09% vs. 12.98%; p = 0.0007). After further adjustment with Cox proportional hazards models, there were still no significant differences in 3-year mortality rates (CABG and/or DES adjusted hazard ratio (AHR): 1.14; 95% confidence interval [CI]: 0.70 to 1.85) or mortality, MI, and/or stroke rates (AHR: 1.15; 95% CI: 0.76 to 1.73), and the repeat revascularization rate remained significantly lower for CABG patients (AHR: 0.54; 95% CI: 0.36 to 0.81).
Despite the higher rating in current guidelines of CABG (Class IIa vs. Class IIb) for patients with isolated PLAD disease, there were no differences in mortality or mortality, MI, and/or stroke, although CABG patients had significantly lower repeat revascularization rates.
Meta-analysis of minimally invasive coronary artery bypass versus drug-eluting stents for isolated left anterior descending coronary artery disease
2014, Journal of Thoracic and Cardiovascular Surgery
To compare the outcomes between minimally invasive coronary artery bypass (MINI-CAB) and drug-eluting stent (DES) implantation for isolated left anterior descending artery disease.
Randomized and observational comparative publications were identified using MEDLINE and Google Scholar databases (January 2003 to December 2013). Studies without outcomes data, without DES use, or using conventional bypass surgery were excluded. The outcomes of interest were cardiac death, myocardial infarction, target vessel revascularization, and periprocedural stroke. Data were compared using the Mantel-Haenszel methods and are presented as odds ratios (ORs), 95% confidence intervals (CIs), and number needed to treat.
From 230 publications, we identified 4 studies (2 randomized and 2 observational) with 941 patients (478 had undergone MINI-CAB and 463 DES implantation). The incidence of target vessel revascularization at maximum follow-up (range, 6-60 months) was significantly lower in the MINI-CAB group (OR, 0.16; 95% CI, 0.08-0.30; P < .0001; number needed to treat, 13). The incidence of cardiac mortality and MI was similar between the MINI-CAB and DES groups during follow-up (OR, 1.05; 95% CI, 0.44-2.47; and OR, 0.83; 95% CI, 0.43-1.58, respectively). In addition, a similar incidence of periprocedural death (OR, 0.85; 95% CI, 0.21-3.47; P = .82), myocardial infarction (OR, 0.98; 95% CI, 0.38-2.58; P = .97), and stroke (OR, 1.36; 95% CI, 0.28-6.70; P = .70) was observed between the 2 treatment modalities.
Given the available evidence, MINI-CAB will result in lower target vessel revascularization rates but otherwise similar clinical outcomes compared with DESs in patients with left anterior descending artery disease.
2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease
2012, Journal of the American College of Cardiology
2011 ACCF/AHA guideline for coronary artery bypass graft surgery
2011, Journal of the American College of Cardiology
Citation Excerpt :
PCI does not lower the long-term risk of MI (370,404,407,409,410,414). The results of 26 RCTs comparing CABG and PCI have been published: Of these, 9 compared CABG with balloon angioplasty (363,393,415–429), 14 compared CABG with BMS implantation (376,430–447), and 3 compared CABG with DES implantation (302,448,449). A systematic review of the 22 RCTs comparing CABG with balloon angioplasty or BMS implantation concluded the following (450):

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ArticlesCoronary angioplasty versus left internal mammary artery grafting for isolated proximal left anterior descending artery stenosis

Abstract

Saphenous vein graft in the surgical treatment of coronary artery disease: operative technique

J Thorac Cardiovasc Surg

Eighteen-year follow-up in the Veterans Affairs cooperative study of coronary artery bypass surgery for stable angina

Circulation

The evolution of medical and surgical therapy for coronary artery disease: a 15-year perspective

JAMA

Nonoperative dilatation of coronary-artery stenosis: percutaneous transluminal coronary angioplasty

N Engl J Med

Coronary angioplasty versus coronary artery bypass surgery: the Randomized Intervention Treatment of Angina (RITA) trial

Lancet

BARI, CABRI, EAST, GABI, and RITA: coronary angioplasty on trial

Lancet

Twelve-year follow-up of survival in the randomized European Coronary Surgery Study

N Engl J Med

A comparison of angioplasty with medical therapy in the treatment of single-vessel coronary artery disease

N Engl J Med

Influence of the internal mammary artery graft on 10-year survival and other cardiac events

N Engl J Med

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Coronary angioplasty versus left internal mammary artery grafting for isolated proximal left anterior descending artery stenosis