Single or multiple arterial bypass graft surgery vs. percutaneous coronary intervention in patients with three-vessel or left main coronary artery disease

Piroze M Davierwala, Chao Gao, Daniel J F M Thuijs, Rutao Wang, Hironori Hara, Masafumi Ono, Thilo Noack, Scot Garg, Neil O'leary, Milan Milojevic, Arie Pieter Kappetein, Marie-Claude Morice, Michael J Mack, Robert-Jan van Geuns, David R Holmes, Mario Gaudino, David P Taggart, Yoshinobu Onuma, Friedrich Wilhelm Mohr, Patrick W Serruys, SYNTAX Extended Survival Investigators, Piroze M Davierwala, Chao Gao, Daniel J F M Thuijs, Rutao Wang, Hironori Hara, Masafumi Ono, Thilo Noack, Scot Garg, Neil O'leary, Milan Milojevic, Arie Pieter Kappetein, Marie-Claude Morice, Michael J Mack, Robert-Jan van Geuns, David R Holmes, Mario Gaudino, David P Taggart, Yoshinobu Onuma, Friedrich Wilhelm Mohr, Patrick W Serruys, SYNTAX Extended Survival Investigators

Abstract

Aim: The aim of this study was to compare long-term all-cause mortality between patients receiving percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) using multiple (MAG) or single arterial grafting (SAG).

Methods and results: The current study is a post hoc analysis of the SYNTAX Extended Survival Study, which compared PCI with CABG in patients with three-vessel (3VD) and/or left main coronary artery disease (LMCAD) and evaluated survival with ≥10 years of follow-up. The primary endpoint was all-cause mortality at maximum follow-up (median 11.9 years) assessed in the as-treated population. Of the 1743 patients, 901 (51.7%) underwent PCI, 532 (30.5%) received SAG, and 310 (17.8%) had MAG. At maximum follow-up, all-cause death occurred in 305 (33.9%), 175 (32.9%), and 70 (22.6%) patients in the PCI, SAG, and MAG groups, respectively (P < 0.001). Multiple arterial grafting [adjusted hazard ratio (HR) 0.66, 95% confidence interval (CI) 0.49-0.89], but not SAG (adjusted HR 0.83, 95% CI 0.67-1.03), was associated with significantly lower all-cause mortality compared with PCI. In patients with 3VD, both MAG (adjusted HR 0.55, 95% CI 0.37-0.81) and SAG (adjusted HR 0.68, 95% CI 0.50-0.91) were associated with significantly lower mortality than PCI, whereas in LMCAD patients, no significant differences between PCI and MAG (adjusted HR 0.90, 95% CI 0.56-1.46) or SAG (adjusted HR 1.11, 95% CI 0.81-1.53) were observed. In patients with revascularization of all three major myocardial territories, a positive correlation was observed between the number of myocardial territories receiving arterial grafts and survival (Ptrend = 0.003).

Conclusion: Our findings suggest that MAG might be the more desirable configuration for CABG to achieve lower long-term all-cause mortality than PCI in patients with 3VD and/or LMCAD.

Trial registration: Registered on clinicaltrial.gov. SYNTAXES: NCT03417050 (https://ichgcp.net/clinical-trials-registry/NCT03417050); SYNTAX: NCT00114972 (https://www.clinicaltrials.gov/ct2/show/NCT00114972).

Keywords: Coronary artery bypass grafting; Multiple arterial grafting; Percutaneous coronary intervention; Single arterial grafting.

© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.

Figures

Graphical Abstract
Graphical Abstract
Kaplan–Meier curves showing all-cause mortality at maximum follow-up. HR, hazard ratio; MAG, multiple arterial grafting; PCI, percutaneous coronary intervention; SAG, single arterial grafting.
Figure 1
Figure 1
Kaplan–Meier curves showing all-cause mortality according to subgroups: (A) left main coronary artery disease; (B) three-vessel disease; (C) diabetes mellitus; (D) non-diabetes mellitus; (E) SYNTAX score <33; and (F) SYNTAX score ≥33. 3VD, three-vessel disease; DM, diabetes mellitus; LM, left main; MAG, multiple arterial grafting; PCI, percutaneous coronary intervention; SAG, single arterial grafting.
Figure 2
Figure 2
Kaplan–Meier curves showing all-cause mortality in patients with grafts anastomosed to or stents implanted in all three myocardial territories. PCI, percutaneous coronary intervention.

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