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CABG is superior to DES (Stent) in MVD - Journal Review
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CABG is superior to DES (Stent) in MVD - Journal Review



Coronary Artery Bypass Graft (CABG) is superior to Drug Eluting Stents (DES) in Multi Vessel Disease (MVD)

Coronary Artery Bypass Graft (CABG) is superior to Drug Eluting Stents (DES) in Multi Vessel Disease (MVD)



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    CABG is superior to DES (Stent) in MVD - Journal Review CABG is superior to DES (Stent) in MVD - Journal Review Presentation Transcript

    • Journal: Annals of Thoracic Surgery  Title: Coronary Artery Bypass (CABG) is superior to Drug-Eluting stents (DES) in multivessel coronary artery disease (MVD).  Author: Robert A. Guyton, MD  Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia.  June/2006, Editorial Review, Vol- 81, Page1949-57.
    • ABSTRACT  PCI continues to displace CABG !! ?? But…  RCTs of PCI Vs CABG in meta-analysis showed clear advantage of survival in CABG.  Drug-Eluting Stents (DES) has no survival benefits over Bare-metal stents (though re-stenosis have).
    • ABSTRACT (Cont…)  Data shows 46% excess mortality in initial PCI than initial CABG.  Ethical consideration should include to inform patients about the documented survival benefits of CABG and more mortality in PCI in all cases.  Only the chest crack in CABG should not be the argue of PCI.
    • INTRODUCTION PCI and CABG for revascularization of CAD compared extensively since 1980s. PCI has improved and more propensity to claim its equivalent survival with a strategy of initial CABG. DES has accelerated the utilization of PCI in patients with MVD.
    • INTRODUCTION (Cont…) This article will show: a) Initial CABG is superior to PCI (bare metal as well as DES) b) Accelerated application of PCI is not warranted c) Patients undergoing PCI are being not informed adequately about the survival benefits of CABG- rather being informed about its hazards and chest crack.
    • Survival Advantage of CABG compared with Medical therapy Large number of RCTs in 1970s & 1980s showed that initial CABG is better than medical therapy for LM disease & TVD with some LV dysfunction.
    • Yusef et al 1 showed the extension of life by initial CABG compared to initial medical therapy. These trials recommended the use of CABG for MVD. Improvement of medical therapy has not supercede the advantage of Surgery.
    • Comparative study of CABG Vs PCI In 1980s, multiple RCTs of PCI Vs CABG were conducted. These area) EAST 3 - The Emory Angioplasty Surgery Trial (n= 5118). b) BARI 6 - Bypass Angioplasty Revascularization Investigations (n=25000).
    • EAST 3, 4, 5 N= 5118 of which 842 were suitable for either PCI or CABG (16.5%). Enrolled= 392 (7.7%), Mean age- 62 years, DVD= 60%, TVD= 40%, 8 Years mortality: CABG= 17.3% PCI= 21.7%
    • BARI 6 18 centers, Period= 1988- 1991, N= 25200. n= 1829 entered to the study (7.3%). Mean age= 61, DVD= 59%, TVD= 41% After 7 Years, Relative survival difference= 15% (p= 0.043) in favors of CABG.
    • BARI: 7-years mortality rate
    • Meta-analysis of 9 RCTs: PTCA Vs CABG in MVD
    • PCI Vs CABG data from Registries of entire populations New York State Cardiac Procedure Registries 12 : Time= 1993- 1995, 3 Years follow up data= a) Repeat revascularization : PCI= 37%, CABG= 3.3%; 11 times higher in PCI group. b) Mortality: PCI= 13.9%, CABG= 9.7%, 43% higher mortality in primary PCI than primary CABG.
    • It is certain that at least in 1993-1995, the enthusiasm of cardiologist for PCI may not have been in the best interest of New York State patients with MVD.
    • RCTs of PCI with stents Vs CABG in MVD 3 RCTs were conducted : a) ARTS 13 = Arterial Revascularization Therapies Study with 5 years follow up. b) ERACI II = Argentine RCT: Coronary Angioplasty with stenting Vs CABG in MVD with 5 years follow up. c) SoS 15 = Stent or Surgery Trial.
    • ARTS 13 67 centers, n= 1205, only 5% were entered and enrolled for study, Mean EF= 61%, Mean age= 61. It was a bias Stent friendly study conducted by Dr. Firth, who was a Vice President of Cordis (Undisclosed) – a division of Johnson and Johnson, the Stent manufacturer and lost its standards of proper RCT.
    • ARTS 13 (Cont…) Though the 5 years follow up results were – Mortality: PCI= 8%, CABG= 7.1%, Rough RR= 1.13. MI, Stroke rate: PCI= 18%, CABG= 13.5%, RR= 1.33. Repeat Revascularization: PCI= 30%, CABG= 8.8%, RR= 3.46.
    • ERACI II 14 Weak surgical team revealed by= CABG volume in 7 centers/year= 57 (1 patient per weak !!, 1 center= 8 patients/year; 0.8 patients/months/center !!!) IMA use= 89% (Institute !!)
    • ERACI II 14 (Cont…) N= 450 MVD, Time= 2 years, & 7 centers (Argentine), Mean age= 61-62, DVD= 40%, TVD= 60%, 30 days mortality: PCI= 0.9%, CABG= 5.6% !! 5 years mortality: PCI= 7.2%, CABG= 11.6%. This study was questionable regarding the efficiency of Surgeons of Argentina !!
    • SoS 15 53 centers in Europe and Canada. n= 988, Randomly assigned. 2 years follow up : Revascularization: PCI= 21%, CABG= 6%, Mortality : PCI= 5%, CABG= 2%.
    • Drug-Eluting Stents (DES) May avoid re-stenosis than Bare metal stents, but ……. No survival difference, no benefit with regard to MI compared with bare metal stents. Distal non-touched lesion reappears again and again (57% re-revascularization needed)
    • British assessment of DES 21 By 10 years, CABG has more life expectancy. Biasness was that, 90% SVD → PCI, 90% MVD → CABG, Cost by 5 years: CABG has less cost than DES (62411 pounds more) and bare metal stents (69619 pounds more). No ground for substitution of CABG by DES in MVD.
    • 3-years mortality for initial CABG(gray) VS initial Stents(black)
    • Stents Vs CABG in clinical practice The New York State Registry Data 23 : Repeat revascularization : PCI= 37% to 35%, CABG= 3.3% to 4.9%. Mortality : DVD including proximal LAD: PCI= 10.2%, CABG= 7.9%, Stent mortality is 29% higher. TVD including proximal LAD: PCI= 15.6%, CABG= 10.7%, Relative mortality is 46% higher in initial PCI than initial CABG.
    • Relative excess mortality with initial stenting Vs initial CABG
    • Observation in appropriate patient education Are patients being informed/ educated properly?? In 1981, Dr. Guyton (Cardiac surgeon) was stood outside the door of a patient’s room and overheard Dr. Gruntzig (Cardiologist), “I can fix your blockage with this little catheter or I can have Dr. Guyton to crack your chest.”- which was overpowering, intuitive and emotional.
    • In 2006, the manner of convincing are ….. “The DES have solved the problem that we used to have with re-stenosis. You read about it in newspaper and you saw it on TV. Let us fix your blockage with the stents. There is no difference in mortality and we can always go back and do a CABG if we have to. I just don’t want you to have your chest cracked.”
    • What are the arguments ?? Surgeons (Dr. Guyton) are not chest cracker. We do have data on CABG Vs PCI. Big difference in mortality. Patients should hear the message (TVD with proximal LAD) “CABG is the best chance of free from angina, and, if you have stenting as your first procedure instead of CABG, you have, on average, a 46% higher chance of dying in 3 years.”
    • Arguments (cont…) Interventionalist should present both the arguments instead of their favored one –?........ Local surgeons are reluctant to argue as the Interventionalist are the source of referrals – which can be sent elsewhere.
    • Conclusions It is responsibility of surgeons to participate aggressively in the decision of revascularization modality for patients with MVD. We must educate properly to Primary care physician, Physician extenders, Non invasive cardiologist, Invasive cardiologist and Patients Lets have the facts to discover.