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

1. JOURNAL PRESENTATION
CABG IS SUPERIOR TO PCI
IN MVD
MODERATOR:
DR. SALEH AHMED, Registrar,
Cardiac Surgery
PRESENTER:
DR. HRIDAY RANJAN ROY

2. 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.

3. 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).

4. 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.

5. 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.

6. 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.

7. 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.

8. 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.

9. 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).

10. 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%

11. 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.

12. BARI: 7-years mortality rate

13. Meta-analysis of 9 RCTs: PTCA
Vs CABG in MVD

14. 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.

15. 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.

16. 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.

17. 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.

18. 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.

19. 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 !!)

20. 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 !!

21. 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%.

22. 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)

23. 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.

24. 3-years mortality for initial
CABG(gray) VS initial Stents(black)

25. 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.

26. Relative excess mortality with
initial stenting Vs initial CABG

27. 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.

28. 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.”

29. 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.”

30. 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.

31. 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.

32. THANK YOU
ALL