Which is better, stent or bypass for left main coronary artery disease?

The left main coronary artery plays an important role in the blood supply of the heart, and more than 75% of the left ventricle is inseparable from the blood supply

However, the optimal revascularization strategy for patients with left main coronary artery disease with moderate to low anatomical complexity is uncertain, drug-eluting stent percutaneous coronary intervention (PCI) versus coronary artery bypass grafting ( CABG, "Bridging" technique) has always been controversial

Recently, a team led by Professor Marc S Sabatine, a cardiovascular specialist at Brigham and Women's Hospital and Harvard Medical School, published important research simultaneously at the American Heart Association (AHA) Scientific Annual Meeting and in The Lancet.

A meta-analysis of data from 4394 patients showed that there was no significant difference in 5-year all-cause mortality between patients who received drug-eluting stents and those who received bypass surgery

Screenshot source: The Lancet

Specifically, the researchers searched 1599 studies and finally included 4 high-quality randomized controlled studies (SYNTAX, PRECOMBAT, NOBLE and EXCEL) for meta-analysis, including 4394 patients with a median SYNTAX score of 25.

The SYNTAX score is a measure of the burden and complexity of coronary atherosclerosis

The primary endpoint of the study was 5-year all-cause mortality, which was 11.

However, the results of Bayesian analysis (inferred probability) are more in favor of bypass surgery, the 5-year mortality rate of drug-eluting stent implantation is 85.

▲5-year all-cause mortality in drug-eluting stent implantation group (PCI) and bypass group (CABG) (Image source: Reference [1])

On secondary endpoints:

The differences in mortality were more attributable to non-cardiovascular deaths

The drug-eluting stent group had more spontaneous MI (6.

Differences in procedural MI between the two treatment strategies depended on the definitions used in different studies

There was also no significant difference in 5-year stroke rates between the drug-eluting stent and bypass groups (2.

▲ Risks of spontaneous myocardial infarction (A), procedural myocardial infarction (BC), stroke (D) and repeat revascularization (E) in drug-eluting stent implantation (PCI) and bypass group (CABG) groups

Professor Sabatine said, "For each patient, these factors need to be considered

At the AHA conference, Dr.

In a concurrent review article of The Lancet, two scholars from McMaster University also said that the existing data is still not enough to distinguish the two, and it is necessary to promote larger clinical trials in this field to solve this problem

References

[1] Marc S Sabatine, et al.
, (2021).
Percutaneous coronary intervention with drug-eluting stents versus coronary artery bypass grafting in left main coronary artery disease: an individual patient data meta-analysis.
The Lancet, DOI: https: https://doi.
org/10.
1016/S0140-6736(21)02334-5

[2] Emilie P Belley-Côté, PJ Devereaux.
(2021).
PCI versus CABG for left main coronary artery disease: is the jury still out?.
The Lancet, DOI: https://doi.
org/10.
1016/S0140- 6736(21)02491-0

[3] Left-Main PCI, CABG Mortality Similar; Choice Remains Complex.
Retrieved November 24, 2021, from https://