New-generation stents compared with coronary bypass surgery for unprotected left main disease: a word of caution

Umberto Benedetto*, David P. Taggart, Miguel Sousa-Uva, Giuseppe Biondi-Zoccai, Antonino Di Franco, Lucas B. Ohmes, Mohamed Rahouma, Mohamed Kamel, Massimo Caputo, Leonard N. Girardi, Gianni D. Angelini, Mario Gaudino

*Corresponding author for this work

Research output: Contribution to journalArticle (Academic Journal)

3 Citations (Scopus)
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Abstract

Background: With the advent of bare metal stents and drug-eluting stents, percutaneous coronary intervention has emerged as an alternative to coronary artery bypass grafting surgery for unprotected left main disease. However, whether the evolution of stents technology has translated into better results after percutaneous coronary intervention remains unclear. We aimed to compare coronary artery bypass grafting with stents of different generations for left main disease by performing a Bayesian network meta-analysis of available randomized controlled trials. Methods: All randomized controlled trials with at least 1 arm randomized to percutaneous coronary intervention with stents or coronary artery bypass grafting for left main disease were included. Bare metal stents and drug-eluting stents of first- and second-generation were compared with coronary artery bypass grafting. Poisson methods and Bayesian framework were used to compute the head-to-head incidence rate ratio and 95% credible intervals. Primary end points were the composite of death/myocardial infarction/stroke and repeat revascularization. Results: Nine randomized controlled trials were included in the final analysis. Six trials compared percutaneous coronary intervention with coronary artery bypass grafting (n = 4654), and 3 trials compared different types of stents (n = 1360). Follow-up ranged from 6 months to 5 years. Second-generation drug-eluting stents (incidence rate ratio, 1.3; 95% credible interval, 1.1-1.6), but not bare metal stents (incidence rate ratio, 0.63; 95% credible interval, 0.27-1.4), and first-generation drug-eluting stents (incidence rate ratio, 0.85; 95% credible interval, 0.65-1.1) were associated with a significantly increased risk of death/myocardial infarction/stroke when compared with coronary artery bypass grafting. When compared with coronary artery bypass grafting, the highest risk of repeat revascularization was observed for bare metal stents (hazard ratio, 5.1; 95% confidence interval, 2.1-14), whereas first-generation drug-eluting stents (incidence rate ratio, 1.8; 95% confidence interval, 1.4-2.4) and second-generation drug-eluting stents (incidence rate ratio, 1.8; 95% confidence interval, 1.4-2.4) were comparable. Conclusions: The introduction of new-generation drug-eluting stents did not translate into better outcomes for percutaneous coronary intervention when compared with coronary artery bypass grafting.

Original languageEnglish
Pages (from-to)2013-2019.e16
JournalJournal of Thoracic and Cardiovascular Surgery
Volume155
Issue number5
Early online date2 Dec 2017
DOIs
Publication statusPublished - 1 May 2018

Structured keywords

  • Centre for Surgical Research

Keywords

  • coronary artery bypass grafting
  • coronary stenting
  • left main disease
  • percutaneous coronary intervention

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    NIHR BRC Cardiovascular

    Angelini, G. D.

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    Cite this

    Benedetto, U., Taggart, D. P., Sousa-Uva, M., Biondi-Zoccai, G., Di Franco, A., Ohmes, L. B., Rahouma, M., Kamel, M., Caputo, M., Girardi, L. N., Angelini, G. D., & Gaudino, M. (2018). New-generation stents compared with coronary bypass surgery for unprotected left main disease: a word of caution. Journal of Thoracic and Cardiovascular Surgery, 155(5), 2013-2019.e16. https://doi.org/10.1016/j.jtcvs.2017.11.066