Randomized trials of PCIs versus CABG surgery: why coronary stenting should remain the first choice of revascularization in non-diabetic patients and why the controversy is still present in diabetics

Abstract

Knowing the best revascularization option for diabetic patients with multiple vessel disease is a challenge without a definitive answer. There have been several randomized clinical trials and subsequent meta-analyses comparing current available technology trying to reach an exhaustive conclusion; comparisons between coronary artery bypass grafts and bare-metal stents, coronary artery bypass grafts and first generation drug-eluting stents and, most recently, first generation versus latest generation drug-eluting stents generated some interesting results. Information provided by pooled data from some of the most important randomized clinical cardiology trials from the last two decades have produced surprising results. The authors analyze these data to discuss the best therapeutic procedures for each patient.

Keywords::

• bare metal stents
• coronary artery bypass surgery
• coronary artery disease
• drug-eluting stents
• graft closure
• randomized trials
• restenosis
• stent thrombosis
• stents

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• If we pooled results from the eight randomized clinical trials between percutaneous coronary interventions with stent implantation, either bare-metal stents (Arterial Revascularization Therapies Study, Argentine randomized trial of percutaneous transluminal coronary angioplasty versus coronary artery bypass surgery in multivessel disease II, Medicine, Angioplasty, or Surgery Study II, Stent or Surgery) or drug-eluting stents (DES; Coronary Artery Revascularization in Diabetes, Future Revascularization Evaluation in patients with Diabetes mellitus: Optimal management of Multivessel disease, SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery and VA CARDS) versus CABG, mortality between percutaneous coronary interventions and CABG in non-diabetic population remained similar.

• Patients with diabetes, if they were treated with coronary angioplasty and implantation of first-generation DES, had a higher risk of death and the composite of death, MI and Cerebrovascular accident (CVA) compared with CABG at long-term follow-up.

• Diabetic patients in randomized clinical trials with bare-metal stents showed a non-significant poor long-term survival, but similar survival freedom from death, MI and CVA compared with CABG.

• Patients with diabetes had threefold increased risk of CVA at 5 years if they were treated with CABG.

• Latest DES designs, compared with the first ones, have been associated with a significant reduction of cardiac death, MI and stent thrombosis.

Notes