Matched Analysis of Surgical versus Percutaneous Revascularization for Left Main Coronary Disease

Comparing percutaneous coronary intervention and coronary artery bypass grafting for left main stenosis on the basis of current regional registry evidence

Objectives

There is an ongoing debate whether percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) is the better choice for treatment of left main (LM) stenosis. We aimed to provide external validation for the recently reviewed guideline recommendations for invasive LM therapy by evaluating the impact of CABG or PCI on long-term survival from local reports of different regions in the world. We performed a systematic review and meta-analysis to address contemporary registry studies comparing PCI and CABG for patients with LM stenosis.

Methods

Three databases were assessed. Our primary end point was long-term all-cause mortality. Secondary end points were major adverse cardiovascular events (MACE), myocardial infarction, repeat revascularization, stroke, and periprocedural mortality. Reconstruction of time-to-event data was performed.

Results

A total of 2477 studies were retrieved. Seven studies with risk-adjusted populations were selected for the analysis. Four studies favored CABG and 3 studies showed no difference for the primary end point. Compared with PCI, patients who underwent CABG had lower risk of death (hazard ratio, 1.15; 95% confidence interval, 1.05-1.26, P < .01) and MACE (hazard ratio, 1.54; 95% confidence interval, 1.40-1.69, P < .01) during follow-up. Moreover, PCI was associated with more myocardial infarction, repeat revascularization, but less strokes when compared with CABG. There was no significant difference regarding periprocedural mortality. The MACE rate was lower after CABG in both early and late phase, which outweighs the higher rate of periprocedural stroke after CABG.

Conclusions

Regional registry evidence supports the current notion of superior long-term endpoints with CABG compared with PCI for the treatment of LM stenosis over time.

Radial artery vs right internal mammary artery as a second conduit during coronary artery bypass grafting

OBJECTIVE

To compare the clinical outcomes of radial artery (RA) grafts during CABG to those of right internal mammary artery (RIMA) grafts.

METHODS

This was a retrospective, single-institution cohort study of isolated CABG with multiple grafts between 2010-2022. To balance graft cohorts, propensity score matching (PSM) was performed using a 1:1 match ratio. Long-term postoperative survival was compared among RA and RIMA groups. Similarly, major adverse cardiac and cerebrovascular events (MACCE) were compared among both cohorts, with MACCE comprising death, myocardial infarction (MI), coronary revascularization, and stroke. Kaplan-Meier estimation was performed for mortality, while cumulative incidence estimation was utilized for MACCE.

RESULTS

A total of 8,774 patients underwent CABG. Of those, 1,674 (19.1%) patients who underwent multiarterial CABG were included in this analysis. 326 (19.5%) patients received RA grafts and 1,348 (80.5%) received RIMA grafts. PSM yielded a cohort of 323 RA patients and 323 RIMA patients. After matching, groups were well-balanced across all baseline variables. No significant differences were observed in immediate postoperative complications or long-term survival, with 5-year survival estimates of 89.5% for the RA group vs 90.1% for the RIMA group. There was a nonsignificant trend toward a higher incidence of MACCE at 5 years in the RA group compared to the RIMA group (31.3% in the RA group vs 24.1% in the RIMA group), especially after 1-year follow-up (21.6% in the RA group vs 15.1% in the RIMA group). Specifically, for RA patients, there were higher rates of repeat revascularization in the 5-year postoperative period (14.7% in the RA group vs 5.3% in the RIMA group), particularly in the territory revascularized by the RA during the index operation (45.7% in the RA group vs 10.3% in the RIMA group).

CONCLUSION

Overall, RA and RIMA secondary conduits for CABG were associated with comparable immediate postoperative complications, 5-year MACCE, and 5-year survival after PSM. RA grafting was associated with significantly higher rates of repeat coronary revascularization at 5 years, specifically in the territory revascularized by the RA during the index operation.

Pre-operative systemic inflammatory response index influences long-term survival rate in off-pump surgical revascularization

Coronary artery bypass revascularization is still the optimal treatment for complex coronary artery disease with good long-term results. The relation between inflammatory activation in the post-operative period and the long-term prognosis was already postulated. The possible predictive role of preoperative inflammatory indexes after the off-pump coronary artery bypass grafting technique on long term survival was the aim of the study. Study population included 171 patients with a median age of 64 years (59-64) operated on using off-pump technique between January and December 2014. Patients enrolled in the current study were followed-up for 8 years. We conducted a multivariable analysis of pre-operative and post-operative inflammatory markers based on analysis of the whole blood count. The overall survival rate was 80% for the total follow-up period, while 34 deaths were reported (30-days mortality rate of 1%). In the multivariable analysis, a pre-operative value of systemic inflammatory response index (SIRI) >1.27 (HR = 6.16, 95% CI 2.17-17.48, p = 0.012) revealed a prognostic value for long-term mortality assessment after off-pump surgery. Preoperative inflammatory activation evaluated by systemic inflammatory reaction index (SIRI) possess a prognostic value for patients with complex coronary artery disease. The SIRI value above 1.27 indicates a worse late prognosis after off-pump coronary artery bypass (AUC = 0.682, p<0.001).