Meta-analysis study comparing percutaneous coronary intervention/drug eluting stent versus coronary artery bypass surgery of unprotected left main coronary artery disease: Clinical outcomes during short-term versus long-term (> 1 year) follow-up

Waleed E Ali, Satyanarayana R Vaidya, Sylvester U Ejeh, Kingsley U Okoroafor, Waleed E Ali, Satyanarayana R Vaidya, Sylvester U Ejeh, Kingsley U Okoroafor

Abstract

Background: Results on the safety and long-term efficacy of drug-eluting stent placement in unprotected left main coronary artery disease (ULMCAD) compared with those of coronary artery bypass surgery (CABG) remain inconsistent across randomized clinical trials and recent meta-analysis studies. We aimed to compare the clinical outcomes and safety over short- and long-term follow-ups by conducting a meta-analysis of large pooled data from randomized controlled trials and up-to-date observational studies.

Methods: A systematic review of PubMed, Google Scholar, Medline, and reference lists of related articles was performed for studies conducted in the drug-eluting stent era, to compare percutaneous coronary intervention (PCI) with CABG in ULMCAD. The primary outcome was major adverse cardiovascular and cerebrovascular events (MACCE), myocardial infarction (MI), stroke, all-cause mortality, and revascularization after at least 1-year follow-up. In-hospital and 30-day clinical outcomes were considered secondary outcomes. Furthermore, a subgroup analysis of studies with ≥5 years follow-up was performed to test the sustainability of clinical outcomes.

Results: A total of 29 studies were extracted with 21,832 patients (10,424 in PCI vs 11,408 in CABG). Pooled analysis demonstrated remarkable differences in long-term follow-up (≥1 year) MACCE (odds ratio [OR] 1.42, 95% CI 1.27-1.59), P < .00001), repeat revascularization (OR 3.00, 95% CI 2.41-3.73, P < .00001), and MI (OR 1.32, 95% CI 1.14-1.53, P = .0002), favoring CABG over PCI. However, stroke risk was significantly lower in the PCI group. Subgroup analysis of studies with ≥5 years follow-up showed similar outcomes except for the noninferiority outcome of MACCE in the PCI arm. However, the PCI group proved good safety profile after a minimum of 30-day follow-up with lower MACCE outcome.

Conclusion: PCI for ULMCAD can be applied with attentiveness in carefully selected patients. MI and the need for revascularization remain drawbacks and areas of concern among previous studies. Nonetheless, it has been proven safe during short-term follow-up.

Conflict of interest statement

The authors have no conflicts of interest to disclose.

Figures

Figure 1
Figure 1
The study flow diagram.
Figure 2
Figure 2
Risk of bias graph: review authors’ judgements about each risk of bias item presented as percentages across all included studies.
Figure 3
Figure 3
Risk of bias summary: review authors’ judgements about each risk of bias item for each included study.
Figure 4
Figure 4
Forest plot of major cardiovascular and cerebrovascular events (MACCE) outcome in percutaneous coronary intervention (PCI) versus coronary artery bypass surgery (CABG) for unprotected left main coronary artery disease (ULMCAD). Forest plot shows the odd ratio (OR) of MACCE in PCI versus CABG during in hospital follow-up (A), 30-day follow-up (B), long-term follow-up ≥ 1 year (C), and subgroup ≥ 5 years follow-up (D).
Figure 5
Figure 5
Forest plot of revascularization outcome in percutaneous coronary intervention (PCI) versus coronary artery bypass surgery (CABG) for unprotected left main coronary artery disease (ULMCAD). Forest plot shows the odd ratio (OR) of revascularization in PCI versus CABG during in hospital follow-up (A), 30-day follow-up (B), long-term follow-up ≥ 1 year (C), and subgroup ≥ 5 years follow-up (D).
Figure 6
Figure 6
Forest Plot of mortality outcome in percutaneous coronary intervention (PCI) versus coronary artery bypass surgery (CABG) for unprotected left main coronary artery disease (ULMCAD). Forest plot shows the odd ratio (OR) of mortality in PCI versus CABG during in hospital follow-up (A), 30-day follow-up (B), long-term follow-up ≥1 year (C), and subgroup ≥ 5 years follow-up (D).
Figure 7
Figure 7
Forest plot of MI outcome in percutaneous coronary intervention (PCI) versus coronary artery bypass surgery (CABG) for unprotected left main coronary artery disease (ULMCAD). Forest plot shows the odd ratio (OR) of myocardial infarction (MI) in PCI versus CABG during in hospital follow-up (A), 30-day follow-up (B), long-term follow-up ≥ 1 year (C), and subgroup ≥ 5 years follow-up (D).
Figure 8
Figure 8
Forest plot of stroke outcome in percutaneous coronary intervention (PCI) versus coronary artery bypass surgery (CABG) for unprotected left main coronary artery disease (ULMCAD). Forest plot shows the odd ratio (OR) of stroke in PCI versus CABG during in hospital follow-up (A), 30-day follow-up (B), long-term follow-up ≥1 year (C), and subgroup ≥ 5 years follow-up (D).

References

    1. Ragosta M, Dee S, Sarembock IJ, et al. Prevalence of unfavorable angiographic characteristics for percutaneous intervention in patients with unprotected left main coronary artery disease. Catheter Cardiovasc Interv 2006;68:357–62.
    1. Chaitman BR, Fisher LD, Bourassa MG, et al. Effect of coronary bypass surgery on survival patterns in subsets of patients with left main coronary artery disease. Report of the Collaborative Study in Coronary Artery Surgery (CASS). Am J Cardiol 1981;48:765–77.
    1. Tan WA, Tamai H, Park SJ, et al. Long-term clinical outcomes after unprotected left main trunk percutaneous revascularization in 279 patients. Circulation 2001;104:1609–14.
    1. Park SJ, Park SW, Hong MK, et al. Long-term (three-year) outcomes after stenting of unprotected left main coronary artery stenosis in patients with normal left ventricular function. Am J Cardiol 2003;91:12–6.
    1. Park SJ, Hong MK, Lee CW, et al. Elective stenting of unprotected left main coronary artery stenosis: effect of debulking before stenting and intravascular ultrasound guidance. J Am Coll Cardiol 2001;38:1054–60.
    1. Qian C, Feng H, Cao J, et al. Meta-analysis of randomized control trials comparing drug-eluting stents versus coronary artery bypass grafting for significant left main coronary narrowing. Am J Cardiol 2017;119:1338–43.
    1. Sá MP, Ferraz PE, Escobar RR, et al. Five-year outcomes following PCI with DES versus CABG for unprotected LM coronary lesions: meta-analysis and meta-regression of 2914 patients. Rev Bras Circ Cardiovasc 2013;28:83–92.
    1. Ahn JM, Roh JH, Kim YH, et al. Randomized trial of stents versus bypass surgery for left main coronary artery disease: 5-year outcomes of the PRECOMBAT study. J Am Coll Cardiol 2015;65:2198–206.
    1. Naganuma T, Chieffo A, Meliga E, et al. Long-term clinical outcomes after percutaneous coronary intervention versus coronary artery bypass grafting for ostial/midshaft lesions in unprotected left main coronary artery from the DELTA registry: a multicenter registry evaluating percutaneous coronary intervention versus coronary artery bypass grafting for left main treatment. JACC Cardiovasc Interv 2014;7:354–61.
    1. Qin Q, Qian J, Wu X, et al. A comparison between coronary artery bypass grafting surgery and percutaneous coronary intervention for the treatment of unprotected left main coronary artery disease. Clin Cardiol 2013;36:54–60.
    1. Ghenim R, Roncalli J, Tidjane AM, et al. One-year follow-up of nonrandomized comparison between coronary artery bypass grafting surgery and drug-eluting stent for the treatment of unprotected left main coronary artery disease in elderly patients (aged > or = 75 years). J Interv Cardiol 2009;22:520–6.
    1. Mäkikallio TH, Niemelä M, Kervinen K, et al. Coronary angioplasty in drug eluting stent era for the treatment of unprotected left main stenosis compared to coronary artery bypass grafting. Ann Med 2008;40:437–43.
    1. Wu X, Chen Y, Kubo T, et al. Long-term (4-year) outcomes and predictors of adverse cardiac events after sirolimus-eluting stent implantation in unprotected left main coronary artery. Int Heart J 2010;51:377–82.
    1. Park DW, Kim YH, Yun SC, et al. Long-term outcomes after stenting versus coronary artery bypass grafting for unprotected left main coronary artery disease: 10-year results of bare-metal stents and 5-year results of drug-eluting stents from the ASAN-MAIN (ASAN Medical Center-Left MAIN Revascularization) Registry. J Am Coll Cardiol 2010;56:1366–75.
    1. Yi G, Youn YN, Hong S, et al. Midterm outcome of off-pump bypass procedures versus drug-eluting stent for unprotected left main coronary artery disease. Ann Thorac Surg 2012;94:15–22.
    1. Cavalcante R, Sotomi Y, Lee CW, et al. Outcomes after percutaneous coronary intervention or bypass surgery in patients with unprotected left main disease. J Am Coll Cardiol 2016;68:999–1009.
    1. Boudriot E, Thiele H, Walther T, et al. Randomized comparison of percutaneous coronary intervention with sirolimus-eluting stents versus coronary artery bypass grafting in unprotected left main stem stenosis. J Am Coll Cardiol 2011;57:538–45.
    1. Sanmartin M, Baz JA, Claro R, et al. Comparison of drug-eluting stents versus surgery for unprotected left main coronary artery disease. Am J Cardiol 2007;100:970–3.
    1. Palmerini T, Marzocchi A, Marrozzini C. Comparison between coronary angioplasty and coronary artery bypass surgery for the treatment of unprotected left main coronary artery stenosis (the Bologna Registry). Am J Cardiol 2006;98:54–9.
    1. Kawecki D, Morawiec B, Fudal M, et al. Comparison of coronary artery bypass grafting with percutaneous coronary intervention for unprotected left main coronary artery disease. Yonsei Med J 2012;53:58–67.
    1. Wei Z, Xie J, Wang K, et al. Comparison of percutaneous coronary intervention versus coronary artery bypass graft in aged patients with unprotected left main artery lesions. Int Heart J 2016;57:682–8.
    1. Lu TM, Lee WL, Hsu PF, et al. Long-term results of stenting versus coronary artery bypass surgery for left main coronary artery disease—a single-center experience. J Chin Med Assoc 2016;79:356–62.
    1. Yu XP, Wu CY, Ren XJ, et al. Very long-term outcomes and predictors of percutaneous coronary intervention with drug-eluting stents versus coronary artery bypass grafting for patients with unprotected left main coronary artery disease. Chin Med J (Engl) 2016;129:763–70.
    1. Morice MC, Serruys PW, Kappetein AP, et al. Five-year outcomes in patients with left main disease treated with either percutaneous coronary intervention or coronary artery bypass grafting in the synergy between percutaneous coronary intervention with taxus and cardiac surgery trial. Circulation 2014;129:2388–94.
    1. Yin Y, Xin X, Geng T, et al. Clinical comparison of percutaneous coronary intervention with domestic drug-eluting stents versus off pump coronary artery bypass grafting in unprotected left main coronary artery disease. Int J Clin Exp Med 2015;8:14376–82.
    1. Shimizu T, Ohno T, Ando J, et al. Mid-term results and costs of coronary artery bypass vs drug-eluting stents for unprotected left main coronary artery disease. Circ J 2010;74:449–55.
    1. Cheng CI, Lee FY, Chang JP, et al. Long-term outcomes of intervention for unprotected left main coronary artery stenosis: coronary stenting vs coronary artery bypass grafting. Circ J 2009;73:705–12.
    1. Park SJ, Kim YH, Park DW, et al. Randomized trial of stents versus bypass surgery for left main coronary artery disease. N Engl J Med 2011;364:1718–27.
    1. Shiomi H, Morimoto T, Furukawa Y, et al. Comparison of percutaneous coronary intervention with coronary artery bypass grafting in unprotected left main coronary artery disease—5-year outcome from CREDO-Kyoto PCI/CABG Registry Cohort-2. Circ J 2015;79:1282–9.
    1. Makikallio T, Holm NR, Lindsay M, et al. Percutaneous coronary angioplasty versus coronary artery bypass grafting in treatment of unprotected left main stenosis (NOBLE): a prospective, randomised, open-label, non-inferiority trial. Lancet 2016;388:2743–52.
    1. Chang K, Koh YS, Jeong SH, et al. Long-term outcomes of percutaneous coronary intervention versus coronary artery bypass grafting for unprotected left main coronary bifurcation disease in the drug-eluting stent era. Heart 2012;98:799–805.
    1. Stone GW, Sabik JF, Serruys PW, et al. Everolimus-eluting stents or bypass surgery for left main coronary artery disease. N Engl J Med 2016;375:2223–35.
    1. Zheng Z, Xu B, Zhang H, et al. Coronary artery bypass graft surgery and percutaneous coronary interventions in patients with unprotected left main coronary artery disease. JACC Cardiovasc Interv 2016;9:1102–11.
    1. Kang SH, Park KH, Choi DJ, et al. Coronary artery bypass grafting versus drug-eluting stent implantation for left main coronary artery disease (from a two-center registry). Am J Cardiol 2010;105:343–51.
    1. Wu C, Hannan EL, Walford G, et al. Utilization and outcomes of unprotected left main coronary artery stenting and coronary artery bypass graft surgery. Ann Thorac Surg 2008;86:1153–9.
    1. Chieffo A, Meliga E, Latib A, et al. Drug-eluting stent for left main coronary artery disease. The DELTA registry: a multicenter registry evaluating percutaneous coronary intervention versus coronary artery bypass grafting for left main treatment. JACC Cardiovasc Interv 2012;5:718–27.
    1. Turner L, Boutron I, Hróbjartsson A, et al. The evolution of assessing bias in Cochrane systematic reviews of interventions: celebrating methodological contributions of the Cochrane Collaboration. Syst Rev 2013;2:79.
    1. Jadad AR, Moore RA, Carroll D, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 1996;17:1–2.
    1. Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol 2010;25:603–5.
    1. Ahn JM, Lee PH, Park SJ. Practical based approach to left main bifurcation stenting. BMC Cardiovasc Disord 2016;16:49.
    1. Biondi-Zoccai GG, Lotrionte M, Moretti C, et al. A collaborative systematic review and meta-analysis on 1278 patients undergoing percutaneous drug-eluting stenting for unprotected left main coronary artery disease. Am Heart J 2008;155:274–83.
    1. Chieffo A, Park SJ, Valgimigli M, et al. Favorable long-term outcome after drug-eluting stent implantation in nonbifurcation lesions that involve unprotected left main coronary artery: a multicenter registry. Circulation 2007;116:158–62.
    1. Chieffo A, Park SJ, Valgimigli M, et al. Ostial and midshaft lesions vs. bifurcation lesions in 1111 patients with unprotected left main coronary artery stenosis treated with drug-eluting stents: results of the survey from the Italian Society of Invasive Cardiology. Eur Heart J 2009;30:2087–94.
    1. Reames BN, Ghaferi AA, Birkmeyer JD, et al. Hospital volume and operative mortality in the modern era. Ann Surg 2014;260:244–51.
    1. Peterson ED, Coombs LP, DeLong ER, et al. Procedural volume as a marker of quality for CABG surgery. JAMA 2004;291:195–201.
    1. Athappan G, Patvardhan E, Tuzcu ME, et al. Left main coronary artery stenosis: a meta-analysis of drug-eluting stents versus coronary artery bypass grafting. JACC Cardiovasc Interv 2013;6:1219–30.
    1. Palmerini T, Biondi-Zoccai G, Reggiani LB, et al. Risk of stroke with coronary artery bypass graft surgery compared with percutaneous coronary intervention. J Am Coll Cardiol 2012;60:798–805.
    1. Roach GW, Kanchuger M, Mangano CM, et al. Adverse cerebral outcomes after coronary bypass surgery. Multicenter Study of Perioperative Ischemia Research Group and the Ischemia Research and Education Foundation Investigators. N Engl J Med 1996;335:1857–63.
    1. Dávila-Román VG, Murphy SF, Nickerson NJ, et al. Atherosclerosis of the ascending aorta is an independent predictor of long-term neurologic events and mortality. J Am Coll Cardiol 1999;33:1308–16.
    1. Bergman P, van der Linden J. Atherosclerosis of the ascending aorta as a major determinant of the outcome of cardiac surgery. Nat Clin Pract Cardiovasc Med 2005;2:246–51.

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