CABG Versus PCI: Greater Benefit in Long-Term Outcomes With Multiple Arterial Bypass Grafting

• Published in: Journal of the American College of Cardiology Vol. 66; no. 13; pp. 1417 - 1427
• Main Authors: Habib, Robert H, Dimitrova, Kamellia R, Badour, Sanaa A, Yammine, Maroun B, El-Hage-Sleiman, Abdul-Karim M, Hoffman, Darryl M, Geller, Charles M, Schwann, Thomas A, Tranbaugh, Robert F
• Format: Journal Article
• Language: English
• Published: United States 29.09.2015
• Subjects: Aged; Coronary Artery Bypass - methods; Coronary Artery Bypass - mortality; Coronary Artery Bypass - trends; Coronary Artery Disease - diagnosis; Coronary Artery Disease - mortality; Coronary Artery Disease - surgery; Coronary Vessels - pathology; Coronary Vessels - surgery; Female; Humans; Male; Middle Aged; Percutaneous Coronary Intervention - methods; Percutaneous Coronary Intervention - mortality; Percutaneous Coronary Intervention - trends; Prospective Studies; Retrospective Studies; Survival Rate - trends; Time Factors; Treatment Outcome; myocardial revascularization; arterial grafting; coronary stents; propensity matching
• ISSN: 0735-1097; 1558-3597
• DOI: 10.1016/j.jacc.2015.07.060

Treatment of multivessel coronary artery disease with traditional single-arterial coronary artery bypass graft (SA-CABG) has been associated with superior intermediate-term survival and reintervention compared with percutaneous coronary intervention (PCI) using either bare-metal stents (BMS) or drug-eluting stents (DES). This study sought to investigate longer-term outcomes including the potential added advantage of multiarterial coronary artery bypass graft (MA-CABG). We studied 8,402 single-institution, primary revascularization, multivessel coronary artery disease patients: 2,207 BMS-PCI (age 66.6 ± 11.9 years); 2,381 DES-PCI (age 65.9 ± 11.7 years); 2,289 SA-CABG (age 69.3 ± 9.0 years); and 1,525 MA-CABG (age 58.3 ± 8.7 years). Patients with myocardial infarction within 24 h, shock, or left main stents were excluded. Kaplan-Meier analysis and Cox regression were used to separately compare 9-year all-cause mortality and unplanned reintervention for BMS-PCI and DES-PCI to respective propensity-matched SA-CABG and MA-CABG cohorts. BMS-PCI was associated with worse survival than SA-CABG, especially from 0 to 7 years (p = 0.015) and to a greater extent than MA-CABG was (9-year follow-up: 76.3% vs. 86.9%; p < 0.001). The surgery-to-BMS-PCI hazard ratios (HR) were as follows: versus SA-CABG, HR: 0.87; and versus MA-CABG, HR: 0.38. DES-PCI showed similar survival to SA-CABG except for a modest 0 to 3 years surgery advantage (HR: 1.06; p = 0.615). Compared with MA-CABG, DES-PCI exhibited worse survival at 5 (86.3% vs. 95.6%) and 9 (82.8% vs. 89.8%) years (HR: 0.45; p <0.001). Reintervention was substantially worse with PCI for all comparisons (all p <0.001). Multiarterial surgical revascularization, compared with either BMS-PCI or DES-PCI, resulted in substantially enhanced death and reintervention-free survival. Accordingly, MA-CABG represents the optimal therapy for multivessel coronary artery disease and should be enthusiastically adopted by multidisciplinary heart teams as the best evidence-based therapy.