Percutaneous Coronary Intervention vs. Coronary Artery Bypass Grafting for Treating In-Stent Restenosis in Unprotected-Left Main: LM-DRAGON-Registry

Wojciech Wańha, Jacek Bil, Michalina Kołodziejczak, Adam Kowalówka, Mariusz Kowalewski, Damian Hudziak, Radosław Gocoł, Rafał Januszek, Tomasz Figatowski, Marek Milewski, Brunon Tomasiewicz, Piotr Kübler, Bruno Hrymniak, Piotr Desperak, Łukasz Kuźma, Krzysztof Milewski, Bartłomiej Góra, Andrzej Łoś, Jan Kulczycki, Adrian Włodarczak, Wojciech Skorupski, Marek Grygier, Maciej Lesiak, Fabrizio D'Ascenzo, Marek Andres, Paweł Kleczynski, Radosław Litwinowicz, Andrea Borin, Grzegorz Smolka, Krzysztof Reczuch, Marcin Gruchała, Robert J Gil, Miłosz Jaguszewski, Krzysztof Bartuś, Piotr Suwalski, Sławomir Dobrzycki, Dariusz Dudek, Stanisław Bartuś, Mariusz Ga Sior, Andrzej Ochała, Alexandra J Lansky, Marek Deja, Jacek Legutko, Elvin Kedhi, Wojciech Wojakowski, Wojciech Wańha, Jacek Bil, Michalina Kołodziejczak, Adam Kowalówka, Mariusz Kowalewski, Damian Hudziak, Radosław Gocoł, Rafał Januszek, Tomasz Figatowski, Marek Milewski, Brunon Tomasiewicz, Piotr Kübler, Bruno Hrymniak, Piotr Desperak, Łukasz Kuźma, Krzysztof Milewski, Bartłomiej Góra, Andrzej Łoś, Jan Kulczycki, Adrian Włodarczak, Wojciech Skorupski, Marek Grygier, Maciej Lesiak, Fabrizio D'Ascenzo, Marek Andres, Paweł Kleczynski, Radosław Litwinowicz, Andrea Borin, Grzegorz Smolka, Krzysztof Reczuch, Marcin Gruchała, Robert J Gil, Miłosz Jaguszewski, Krzysztof Bartuś, Piotr Suwalski, Sławomir Dobrzycki, Dariusz Dudek, Stanisław Bartuś, Mariusz Ga Sior, Andrzej Ochała, Alexandra J Lansky, Marek Deja, Jacek Legutko, Elvin Kedhi, Wojciech Wojakowski

Abstract

Background: Data regarding management of patients with unprotected left main coronary artery in-stent restenosis (LM-ISR) are scarce.

Objectives: This study investigated the safety and effectiveness of percutaneous coronary intervention (PCI) vs. coronary artery bypass grafting (CABG) for the treatment of unprotected LM-ISR.

Methods: Consecutive patients who underwent PCI or CABG for unprotected LM-ISR were enrolled. The primary endpoint was a composite of major adverse cardiac and cerebrovascular events (MACCE), defined as cardiac death, myocardial infarction (MI), target vessel revascularization (TVR), and stroke.

Results: A total of 305 patients were enrolled, of which 203(66.6%) underwent PCI and 102(33.4%) underwent CABG. At 30-day follow-up, a lower risk of cardiac death was observed in the PCI group, compared with the CABG-treated group (2.1% vs. 7.1%, HR 3.48, 95%CI 1.01-11.8, p = 0.04). At a median of 3.5 years [interquartile range (IQR) 1.3-5.5] follow-up, MACCE occurred in 27.7% vs. 29.6% (HR 0.82, 95%CI 0.52-1.32, p = 0.43) in PCI- and CABG-treated patients, respectively. There were no significant differences between PCI and CABG in cardiac death (9.9% vs. 18.4%; HR 1.56, 95%CI 0.81-3.00, p = 0.18), MI (7.9% vs. 5.1%, HR 0.44, 95%CI 0.15-1.27, p = 0.13), or stroke (2.1% vs. 4.1%, HR 1.79, 95%CI 0.45-7.16, p = 0.41). TVR was more frequently needed in the PCI group (15.2% vs. 6.1%, HR 0.35, 95%CI 0.15-0.85, p = 0.02).

Conclusions: This analysis of patients with LM-ISR revealed a lower incidence of cardiac death in PCI compared with CABG in short-term follow-up. During the long-term follow-up, no differences in MACCE were observed, but patients treated with CABG less often required TVR.

Visual overview: A visual overview is available for this article.

Registration: https://www.clinicaltrials.gov; Unique identifier: NCT04968977.

Keywords: coronary artery bypass graft (CABG); in-stent restenosis (ISR); left main; percutaneous coronary intervention (complex PCI); stents (Coronary).

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2022 Wańha, Bil, Kołodziejczak, Kowalówka, Kowalewski, Hudziak, Gocoł, Januszek, Figatowski, Milewski, Tomasiewicz, Kübler, Hrymniak, Desperak, Kuźma, Milewski, Góra, Łoś, Kulczycki, Włodarczak, Skorupski, Grygier, Lesiak, D'Ascenzo, Andres, Kleczynski, Litwinowicz, Borin, Smolka, Reczuch, Gruchała, Gil, Jaguszewski, Bartuś, Suwalski, Dobrzycki, Dudek, Bartuś, Ga̧sior, Ochała, Lansky, Deja, Legutko, Kedhi and Wojakowski.

Figures

Figure 1
Figure 1
Kaplan–Meier curves for MACCE according to type of treatment. Major adverse cardiac and cerebrovascular events (MACCE) is the composite of target vessel revascularization, myocardial infarction, stroke, or cardiac death. CABG, coronary artery bypass grafting; PCI, percutaneous coronary intervention.
Figure 2
Figure 2
Kaplan–Meier curves for cumulative incidence of secondary outcomes according to type of treatment. CABG, coronary artery bypass grafting; MI, myocardial infarction; PCI, percutaneous coronary intervention; TVR, target vessel revascularization.
Figure 3
Figure 3
Risk of MACCE at long-term follow-up. CABG, coronary artery bypass grafting; CI, confidence interval; CKD, chronic kidney disease; HR, hazard ratio; ISR, in-stent restenosis; LM, left main coronary artery; LVEF, left ventricular ejection fraction; MI, myocardial infarction; PCI, percutaneous coronary intervention; STS, Society of Thoracic Surgeons.

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