Percutaneous coronary intervention (PCI)vs minimally invasive coronary artery bypass grafting

A recent meta-analysis in British Medical Journal¹compared the outcomes between minimally invasive left internal thoracic artery bypass and percutaneous coronary artery stenting as primary interventions for isolated lesions of the left anterior descending artery (LAD). The outcomes from 12 studies were analysed.

For isolated lesions of LAD, minimally invasive left internal thoracic artery bypass proved to be have less complications in the mid term. There was no significant mortality difference between the two groups.

A cost effective analysis was also published by the same investigators² which suggested that the minimally invasive left internal thoracic artery bypass may be more cost effective in the medium and long term.

On the face of it, there appears to be a clear advantage for CABG, but other factors need to be considered.

Even though drug eluting stents have revolutionised interventional cardiology, the meta-analysis has not included studies with these newer stents. It is unlikely that the drug eluting stents will match the survival benefits of CABG and brings with them the additional problems of late stent thrombosis and long term anti thrombotics. Prof. Westaby and colleagues have noted that minimally invasive CABG is rarely performed in the UK and the costs calculation was more reflective of the economics 10 years ago.³

So where do we stand regarding the debate of PCI vs CABG.

For proximal LAD lesions minimally invasive CABG results reduced re-intervention and event rates but no mortality benefit. So patient’s choice will play a significant role. Many patients will still prefer a less invasive PCI strategy.

In those patients having multivessel disease with left main stem lesion, CABG offers reduced re-intervention rates and marginally better survival. Ongoing Syntax trial will hopefully provide the answers regarding which is a clearly better strategy.⁴

References

(1) Aziz O, Rao C, Panesar SS, Jones C, Morris S, Darzi A et al. Meta-analysis of minimally invasive internal thoracic artery bypass versus percutaneous revascularisation for isolated lesions of the left anterior descending artery. BMJ 2007; 334(7594):617.

(2) Rao C, Aziz O, Panesar SS, Jones C, Morris S, Darzi A et al. Cost effectiveness analysis of minimally invasive internal thoracic artery bypass versus percutaneous revascularisation for isolated lesions of the left anterior descending artery. BMJ 2007; 334(7594):621.

(3) Westaby S, Channon K, Banning A. A sterile debate. BMJ 2007; 335(7611):111.

(4) Ong AT, Serruys PW, Mohr FW, Morice MC, Kappetein AP, Holmes DR, Jr. et al. The SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery (SYNTAX) study: design, rationale, and run-in phase. Am Heart J 2006; 151(6):1194-1204.