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| TITLE |
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Long-term outcomes of coronary-artery bypass grafting versus stent implantation.
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| AUTHORS |
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Edward L. Hannan, Michael J. Racz, Gary Walford, Robert H Jones, Thomas J. Ryan, Edward Bennett, Alfred T Culliford, Wayne Isom, Jeffrey P Gold, Eric A Rose
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| PUBLICATION INFORMATION |
Journal Name: The New England Journal of Medicine
Volume: 352(21)
Pages: 2174-83
Date Published: 05/26/2005
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| ABSTRACT/REVIEW |
What were the researchers trying to learn in this study?
They wanted to compare long-term results of two treatments for narrowed coronary arteries. They wanted to determine whether patients with coronary artery disease in more than one artery survived longer and with fewer additional procedures when treated with coronary artery bypass grafting (CABG), or with balloon angioplasty with a stent (PCI).
Coronary artery bypass surgery involves transplanting a section of artery or vein from one place in the body and grafting it into one of the arteries serving the heart. The transplanted section transports the blood around a section of the artery narrowed or blocked by plaque, thus "bypassing" the blockage.
Angioplasty with a stent is a procedure that reopens blocked blood vessels to the heart. A physician inserts a hollow tube (catheter) with a small deflated balloon in its tip into the blocked section of the artery. Then the physician inflates the balloon to widen the artery. A coronary stent is a small wire mesh tube implanted in the artery to hold it open and increase blood flow.
What did they find?
Half of the 37,212 patients treated with CABG had been followed for more than 706 days (range, 328 to 1089) and half of the 22,102 patients treated with a stent had been followed for more than 585 days (range, 265 to 948) at the time of the analysis.
After adjusting for survival risk, such as age and other illnesses, they found that significantly more patients in the CABG group survived than those who received a stent. The factors most strongly associated with those who died included impaired pumping capacity (lower ejection fraction), diabetes, heart failure, chronic obstructive pulmonary disease, carotid artery disease, narrowed arteries in the lower trunk (aortoiliac disease) or upper legs (femoral or popliteal disease), shock, kidney failure, stroke, advanced age, and male gender. Only patients with no disease found in the left anterior descending coronary artery fared as well with PCI and stent as with those treated with CABG.
Also, the percentage of those treated with CABG who needed a second procedure to open arteries within 3 years of the first procedure was significantly lower than the percentage of stent patients who underwent a second procedure within 3 years of the first. In the CABG group 0.3% underwent a repeat bypass procedure and 4.6% underwent a stent procedure in the first 3 years after the first surgery. In the 3 years after procedure in the stent group, 7.8% underwent a subsequent bypass procedure and 27.3% had repeat stent procedure.
Who was studied?
The study included New York residents with coronary artery disease in multiple arteries (multivessel disease), which was defined as a narrowing (stenosis) of at least 70% in at least two of the three main coronary arteries. The study group comprised 37,212 patients who underwent CABG at 34 hospitals and 22,102 patients who underwent stenting at 35 hospitals between Jan. 1, 1997 and Dec. 31, 2000.
Patients who had previously undergone revascularization, those with disease of the left main coronary artery (defined as stenosis of more than 50 percent), and those who had a heart attack (acute myocardial infarction) within 24 hours before the procedure were excluded.
How was the study done?
The authors used data from a very large registry to compare short-term and long-term outcomes among patients with multivessel disease who underwent CABG or stenting in New York State hospitals between Jan. 1, 1997 and Dec 31, 2000.
They determined the rates of death and subsequent repeat procedures (revascularization) within 3 years after the procedure in various groups of patients according to the number of diseased vessels and the presence or absence of involvement of the left anterior descending (LAD) coronary artery. The rates of adverse outcomes were adjusted to account for differences in patients' severity of illness before revascularization.
What did researchers know before starting this study?
Coronary artery bypass grafting (CABG) and balloon angioplasty (percutaneous coronary intervention, PCI) have long been the standard aggressive options for treating patients with coronary artery disease. In the past few years several randomized clinical trials and observational studies have examined the relative long-term benefits of these treatments. With few exceptions, however, these studies were conducted before the availability of stents, placed in conjunction with balloon angioplasty to hold the vessel open longer.
Why did they do it?
They wanted to see if the use of stents to open multiple narrowed coronary arteries improves the short- and long-term outcomes of balloon angioplasty (PCI) as compared to coronary artery bypass graft (CABG).
What did the researchers say their study results mean?
For patients with two or more diseased coronary arteries, CABG is associated with higher adjusted rates of long-term survival than stenting. Choosing an intervention for patients with reduced blood flow to the heart muscle (ischemic heart disease), however, involves many considerations. Stent implantation has a much lower in-hospital mortality rate than CABG and stenting is far less invasive than CABG, consequently many patients may prefer to have one or more stents implanted in the hope of avoiding CABG.
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