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Meta-analysis of Four Randomized Controlled Trials on Long-Term Outcomes of Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention With Stenting for Multivessel Coronary Artery Disease
Meta-analysis of Four Randomized Controlled Trials on Long-Term Outcomes of Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention With Stenting for Multivessel Coronary Artery Disease Hisato Takagi, MD, PhD*, Norikazu Kawai, MD, and Takuya Umemoto, MD, PhD To provide a quantitative analysis of long-term clinical outcomes, a meta-analysis of 4 randomized controlled trials of percutaneous coronary intervention (PCI) with stenting versus coronary artery bypass grafting (CABG) for multivessel coronary artery disease was conducted. The search identified 4 randomized controlled trials of PCI with stenting versus CABG that enrolled patients with multivessel coronary artery disease. In conclusion, pooled analysis demonstrated no statistically significant differences in death, cardiac death, Q-wave myocardial infarction, cerebrovascular accidents, and angina pectoris between PCI with stenting and CABG. However, PCI with stenting was associated with a statistically significant increase in subsequent PCI, subsequent CABG, subsequent revascularization (PCI or CABG), and major adverse cardiovascular events relative to CABG. © 2008 Elsevier Inc. All rights reserved. (Am J Cardiol 2008;101:1259 –1262) According to a meta-analysis by Mercado et al1 of individual patient data from randomized controlled trials (RCTs), percutaneous coronary intervention (PCI) with stenting (PCI-S) and coronary artery bypass grafting (CABG) provided similar degrees of protection against death, myocardial infarction, and stroke for patients with multivessel coronary artery disease (CAD) 1 year after the initial procedures. Repeat revascularization procedures, however, remained high after PCI-S. In contrast, the long-term outcomes of several RCTs have been recently reported. To provide a quantitative analysis of long-term clinical outcomes, we performed a meta-analysis of currently available RCTs of PCI-S versus CABG for multivessel CAD. Methods and Results All English-language RCTs of PCI-S versus CABG that enrolled patients with multivessel CAD were identified using a 2-level search strategy. First, public-domain databases, including Medline, EMBASE, and the Cochrane Central Register of Controlled Trials, were searched using Web-based search engines (PubMed and OVID). Second, relevant studies were identified through a manual search of secondary sources including reference lists of initially identified articles and a search of reviews and commentaries. The Medline database was searched for articles published from January 1966 to March 2007. Medical Subject Heading keywords included “angio-
Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan. Manuscript received October 24, 2007; revised manuscript received and accepted December 9, 2007. *Corresponding author: Tel: 81-55-975-2000; fax: 81-55-975-2725. E-mail address: [email protected] (H. Takagi). 0002-9149/08/$ – see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.amjcard.2007.12.026
plasty, transluminal, percutaneous coronary,” “stents”, “coronary artery bypass,” and “randomized controlled trials.” The EMBASE database (January 1991 to the first quarter of 2007) and the Cochrane Library and Central Register of Controlled Trials (current through the first quarter of 2007) were searched using OVID exploding keywords including “percutaneous transluminal coronary angioplasty,” “percutaneous coronary intervention,” “stent,” “coronary artery bypass,” “clinical trial,” and “randomized clinical trial.” Studies considered for inclusion met the following criteria: the design was a RCT, the study population was patients with multivessel CAD, patients were randomly assigned to PCI-S versus CABG, and main outcomes included major adverse cardiovascular events (MACEs). Data regarding detailed inclusion criteria, duration of follow-up, and MACEs were abstracted (as available) from each study. For each study, data regarding MACEs in the PCI-S and CABG groups were used to generate risk ratios and 95% confidence intervals. Study-specific estimates were combined using inverse variance-weighted averages of logarithmic risk ratios in a random-effects model. Between-study heterogeneity was analyzed by means of standard chi-square tests, with p values ⬍0.05 deemed statistically significant. Publication bias was assessed mathematically using an adjusted rank correlation test. Our search identified 4 RCTs of PCI-S (all using bare-metal stents) versus CABG that enrolled patients with multivessel CAD. The analyzed trials were the Stent or Surgery (SoS) trial,2 the Arterial Revascularization Therapies Study (ARTS),3 Estudio Randomizado Argentino de Angioplastia vs Cirugia (ERACI) II,4 and the Medicine, Angioplasty, or Surgery Study (MASS) II.5 We excluded the Angina With Extremely Serious Operative Mortality Evaluation (AWESOME),6 because the trial included patients with previous heart surgery, ongowww.AJConline.org
1260
Table 1 Characteristics of trials and meta-analyses of outcomes SoS2
ARTS3
ERACI II4
Follow-up (yrs) Enrollment diagnosis
2* (1–4)† Stable/unstable angina
Exclusion
MI ⱕ48 h
5 Stable/unstable angina or silent ischemia Transmural MI ⱕ1 week
5 Stable/unstable angina or silent ischemia MI ⱕ24 h
Variable
450 225/225 62.5 ⫾ 11.5/61.4 ⫾ 10.1 77.3/81.4 NR (ⱖ 35‡)
p Value of Heterogeneity
ⱖ5 Stable angina/silent ischemia MI/unstable angina requiring emergency revascularization 408 205/203 60 ⫾ 9/60 ⫾ 9 67/72 67 ⫾ 8/67 ⫾ 9
22 (4.5)/8 (1.6) 2.82 (1.27–6.27)
48 (8.0)/46 (7.6) 1.05 (0.71–1.55)
16 (7.1)/26 (11.6) 0.62 (0.34–1.12)
32 (15.5)/26 (12.8) 1.22 (0.75–1.97)
118 (7.8)/106 (6.9) 1.15 (0.72–1.85) 0.97 (0.68–1.38)§
0.0267
Cardiac death PCI-S/CABG, n (%) RR (95% CI)
9 (1.8)/4 (0.8) 2.31 (0.71–7.44)
21 (3.5)/17 (2.8) 1.25 (0.66–2.34)
12 (5.3)/21 (9.3) 0.57 (0.29–1.13)
24 (11.7)/16 (7.9) 1.49 (0.81–2.71)
66 (4.3)/58 (3.8) 1.16 (0.69–1.95) 1.04 (0.59–1.81)§
0.1062
Nonfatal Q-wave MI PCI-S/CABG, n (%) RR (95% CI)
26 (5.3)/41 (8.2)储 0.65 (0.40–1.05)
40 (6.7)/34 (5.6) 1.19 (0.76–1.85)
6 (2.7)/14 (6.2) 0.43 (0.17–1.10)
23 (11.2)/17 (8.4) 1.34 (0.74–2.43)
95 (6.3)/106 (6.9) 0.88 (0.56–1.38) 1.00 (0.58–1.70)§
0.0603
Subsequent PCI PCI-S/CABG, n (%) RR (95% CI)
64 (13.1)/25 (5.0) 2.62 (1.68–4.09)
139 (23.2)/50 (8.3) 2.80 (2.07–3.79)
47 (22.9)/5 (2.5) 9.31 (3.78–22.92)
250 (19.3)/80 (6.1) 3.48 (2.07–5.84) 4.72 (1.47–15.16)§
0.0368
Subsequent CABG PCI-S/CABG, n (%) RR (95% CI)
44 (9.0)/5 (1.0) 9.02 (3.61–22.55)
63 (10.5)/7 (1.2) 9.08 (4.19–19.65)
19 (9.3)/2 (1.0) 9.41 (2.22–39.87)
145 (9.6)/14 (1.1) 9.10 (5.27–15.72) 9.15 (4.63–18.08)§
0.9988
Subsequent revascularization PCI-S/CABG, n (%) RR (95% CI)
101 (20.7)/30 (6.0) 3.45 (2.34–5.08)
182 (30.3)/53 (8.8) 3.46 (2.61–4.60)
66 (32.2)/7 (3.4) 9.34 (4.39–19.86)
413 (27.2)/107 (7.0) 4.01 (2.93–5.49) 4.46 (2.76–7.22)§
0.1071
NR —
23 (3.8)/21 (3.5) 1.10 (0.62–1.97)
7 (3.4)/12 (58.9) 0.58 (0.23–1.44)
30 (3.7)/33 (4.1) 0.88 (0.48–1.61)
0.2400
NR —
250 (41.7)/132 (21.8)¶ 1.91 (1.60–2.28)
113 (55.1)/30 (14.8)** 3.73 (2.62–5.31)
441 (42.8)/215 (20.8) 2.16 (1.38–3.37)
0.0003
NR —
19 (8.4)/NR —
64 (28.4)/17 (7.6) 3.76 (2.28–6.22)
NR — 78 (34.7)/53 (23.6)# 1.47 (1.09–1.98)
3,051 1,518/1,533 The American Journal of Cardiology (www.AJConline.org)
1,205 600/605 61 ⫾ 10/61 ⫾ 9 77/76 61 ⫾ 12/60 ⫾ 13
Combined
Patients PCI-S/CABG Mean age (PCI-S/CABG) (yrs) Men (PCI-S/CABG) (%) Mean ejection fraction (PCI-S/CABG) (%) Death PCI-S/CABG, n (%) RR (95% CI)
CVA PCI-S/CABG, n (%) RR (95% CI) MACEs PCI-S/CABG, n (%) RR (95% CI)
988 488/500 61 ⫾ 9.2/62 ⫾ 9.5 80/78 57/57
MASS II5
0.0329 * Median. † Range. ‡ Inclusion criteria. § Combined estimate eliminating the SoS trial. 储 Q-wave MI. ¶ Death, nonfatal MI, revascularization, or CVA. # Death, nonfatal Q-wave MI, revascularization, or CVA. ** Death, nonfatal Q-wave MI, or revascularization. CI ⫽ confidence interval; CVA ⫽ cerebrovascular accident; MI ⫽ myocardial infarction; NR ⫽ not reported; RR ⫽ risk ratio.
19.8/17.9 1.01 (0.70–1.46) 22.7/25.9 0.88 (0.60–1.29) 14.0/18.0 0.78 (0.51–1.19) 21.2/15.5 1.36 (1.07–1.73) NR — Angina PCI-S/CABG (%) RR (95% CI)
MASS II5 ERACI II4 ARTS3 SoS2 Variable
Table 1 (continued)
Combined
p Value of Heterogeneity
Coronary Artery Disease/Outcomes of CABG Versus Stenting
1261
ing or very recent myocardial infarctions, and left ventricular ejection fractions ⬍35%, which are clearly different from the characteristics of the 4 other trials. In total, our meta-analysis included data on 3,051 patients (Table 1). Anticoagulation regimens after the procedures were not reported in all trials, but aspirin was used in 80% and 70% of the PCI-S and CABG groups, respectively, during 1 year of follow-up in MASS II.7 Pooled analysis demonstrated no statistically significant differences in death, cardiac death, Q-wave myocardial infarction, cerebrovascular accidents, and angina between PCI-S and CABG. However, PCI-S was associated with statistically significant increases in subsequent PCI, subsequent CABG, subsequent revascularization (PCI or CABG), and MACEs relative to CABG. There was significant trial heterogeneity of death, subsequent PCI, MACEs, and angina. There was no evidence of a significant publication bias, except for subsequent revascularization (p ⫽ 0.0415). To assess the impact of qualitative heterogeneity in trial design on the pooled effect estimate, we performed a sensitivity analysis. Eliminating the SoS trial, with short follow-up (1 to 4 years), did not substantially change the pooled point estimate. Discussion The main limitation of the previous meta-analysis by Mercado et al1 of RCTs of PCI-S versus CABG for multivessel CAD was the relatively short follow-up period, limited to 1 year. The present meta-analysis of long-term follow-up of 4 currently available RCTs demonstrated higher subsequent revascularization and MACEs in PCI-S compared with CABG, reinforcing the results of the previous meta-analysis.1 Insofar as singlevessel (left anterior descending coronary artery) CAD is concerned, a meta-analysis by Aziz et al8 demonstrated that PCI-S was fraught with significantly increased risk for subsequent revascularization and MACEs in comparison with minimally invasive direct CABG. Therefore, for single-vessel and mutivessel CAD, CABG surpasses PCI-S in the reduction of subsequent revascularization and MACEs. 1. Mercado N, Wijns W, Serruys PW, Sigwart U, Flather MD, Stables RH, O’Neill WW, Rodriguez A, Lemos PA, Hueb WA, et al. Oneyear outcomes of coronary artery bypass graft surgery versus percutaneous coronary intervention with multiple stenting for multisystem disease: a meta-analysis of individual patient data from randomized clinical trials. J Thorac Cardiovasc Surg 2005;130:512–519. 2. SoS Investigators. Coronary artery bypass surgery versus percutaneous coronary intervention with stent implantation in patients with multivessel coronary artery disease (the Stent or Surgery trial): a randomised controlled trial. Lancet 2002;360:965–970. 3. Serruys PW, Ong AT, van Herwerden LA, Sousa JE, Jatene A, Bonnier JJ, Schonberger JP, Buller N, Bonser R, Disco C, et al. Five-year outcomes after coronary stenting versus bypass surgery for the treatment of multivessel disease: the final analysis of the Arterial Revascularization Therapies Study (ARTS) randomized trial. J Am Coll Cardiol 2005;46:575–581. 4. Rodriguez AE, Baldi J, Fernandez Pereira C, Navia J, Rodriguez Alemparte M, Delacasa A, Vigo F, Vogel D, O’Neill W, Palacios IF; ERACI II Investigators. Five-year follow-up of the Argentine random-
1262
The American Journal of Cardiology (www.AJConline.org)
ized trial of coronary angioplasty with stenting versus coronary bypass surgery in patients with multiple vessel disease (ERACI II). J Am Coll Cardiol 2005;46:582–588. 5. Hueb W, Lopes NH, Gersh BJ, Soares P, Machado LA, Jatene FB, Oliveira SA, Ramires JA. Five-year follow-up of the Medicine, Angioplasty, or Surgery Study (MASS II): a randomized controlled clinical trial of 3 therapeutic strategies for multivessel coronary artery disease. Circulation 2007;115:1082–1089. 6. Hueb W, Soares PR, Gersh BJ, César LA, Luz PL, Puig LB, Martinez EM, Oliveira SA, Ramires JA. The Medicine, Angioplasty, or Surgery Study (MASS-II): a randomized, controlled clinical trial of three therapeutic strategies for multivessel coronary artery disease: one-year results. J Am Coll Cardiol 2004;43:1743–1751.
7. Morrison DA, Sethi G, Sacks J, Henderson W, Grover F, Sedlis S, Esposito R, Ramanathan K, Weiman D, Saucedo J, et al, for the Investigators of the Department of Veterans Affairs Cooperative Study 385 the Angina With Extremely Serious Operative Mortality Evaluation (AWESOME). Percutaneous coronary intervention versus coronary artery bypass graft surgery for patients with medically refractory myocardial ischemia and risk factors for adverse outcomes with bypass: a multicenter, randomized trial. J Am Coll Cardiol 2001;38:143–149. 8. Aziz O, Rao C, Panesar SS, Jones C, Morris S, Darzi A, Athanasiou T. Meta-analysis of minimally invasive internal thoracic artery bypass versus percutaneous revascularisation for isolated lesions of the left anterior descending artery. BMJ 2007;334:617.
Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan. Manuscript received October 24, 2007; revised manuscript received and accepted December 9, 2007. *Corresponding author: Tel: 81-55-975-2000; fax: 81-55-975-2725. E-mail address: [email protected] (H. Takagi). 0002-9149/08/$ – see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.amjcard.2007.12.026
plasty, transluminal, percutaneous coronary,” “stents”, “coronary artery bypass,” and “randomized controlled trials.” The EMBASE database (January 1991 to the first quarter of 2007) and the Cochrane Library and Central Register of Controlled Trials (current through the first quarter of 2007) were searched using OVID exploding keywords including “percutaneous transluminal coronary angioplasty,” “percutaneous coronary intervention,” “stent,” “coronary artery bypass,” “clinical trial,” and “randomized clinical trial.” Studies considered for inclusion met the following criteria: the design was a RCT, the study population was patients with multivessel CAD, patients were randomly assigned to PCI-S versus CABG, and main outcomes included major adverse cardiovascular events (MACEs). Data regarding detailed inclusion criteria, duration of follow-up, and MACEs were abstracted (as available) from each study. For each study, data regarding MACEs in the PCI-S and CABG groups were used to generate risk ratios and 95% confidence intervals. Study-specific estimates were combined using inverse variance-weighted averages of logarithmic risk ratios in a random-effects model. Between-study heterogeneity was analyzed by means of standard chi-square tests, with p values ⬍0.05 deemed statistically significant. Publication bias was assessed mathematically using an adjusted rank correlation test. Our search identified 4 RCTs of PCI-S (all using bare-metal stents) versus CABG that enrolled patients with multivessel CAD. The analyzed trials were the Stent or Surgery (SoS) trial,2 the Arterial Revascularization Therapies Study (ARTS),3 Estudio Randomizado Argentino de Angioplastia vs Cirugia (ERACI) II,4 and the Medicine, Angioplasty, or Surgery Study (MASS) II.5 We excluded the Angina With Extremely Serious Operative Mortality Evaluation (AWESOME),6 because the trial included patients with previous heart surgery, ongowww.AJConline.org
1260
Table 1 Characteristics of trials and meta-analyses of outcomes SoS2
ARTS3
ERACI II4
Follow-up (yrs) Enrollment diagnosis
2* (1–4)† Stable/unstable angina
Exclusion
MI ⱕ48 h
5 Stable/unstable angina or silent ischemia Transmural MI ⱕ1 week
5 Stable/unstable angina or silent ischemia MI ⱕ24 h
Variable
450 225/225 62.5 ⫾ 11.5/61.4 ⫾ 10.1 77.3/81.4 NR (ⱖ 35‡)
p Value of Heterogeneity
ⱖ5 Stable angina/silent ischemia MI/unstable angina requiring emergency revascularization 408 205/203 60 ⫾ 9/60 ⫾ 9 67/72 67 ⫾ 8/67 ⫾ 9
22 (4.5)/8 (1.6) 2.82 (1.27–6.27)
48 (8.0)/46 (7.6) 1.05 (0.71–1.55)
16 (7.1)/26 (11.6) 0.62 (0.34–1.12)
32 (15.5)/26 (12.8) 1.22 (0.75–1.97)
118 (7.8)/106 (6.9) 1.15 (0.72–1.85) 0.97 (0.68–1.38)§
0.0267
Cardiac death PCI-S/CABG, n (%) RR (95% CI)
9 (1.8)/4 (0.8) 2.31 (0.71–7.44)
21 (3.5)/17 (2.8) 1.25 (0.66–2.34)
12 (5.3)/21 (9.3) 0.57 (0.29–1.13)
24 (11.7)/16 (7.9) 1.49 (0.81–2.71)
66 (4.3)/58 (3.8) 1.16 (0.69–1.95) 1.04 (0.59–1.81)§
0.1062
Nonfatal Q-wave MI PCI-S/CABG, n (%) RR (95% CI)
26 (5.3)/41 (8.2)储 0.65 (0.40–1.05)
40 (6.7)/34 (5.6) 1.19 (0.76–1.85)
6 (2.7)/14 (6.2) 0.43 (0.17–1.10)
23 (11.2)/17 (8.4) 1.34 (0.74–2.43)
95 (6.3)/106 (6.9) 0.88 (0.56–1.38) 1.00 (0.58–1.70)§
0.0603
Subsequent PCI PCI-S/CABG, n (%) RR (95% CI)
64 (13.1)/25 (5.0) 2.62 (1.68–4.09)
139 (23.2)/50 (8.3) 2.80 (2.07–3.79)
47 (22.9)/5 (2.5) 9.31 (3.78–22.92)
250 (19.3)/80 (6.1) 3.48 (2.07–5.84) 4.72 (1.47–15.16)§
0.0368
Subsequent CABG PCI-S/CABG, n (%) RR (95% CI)
44 (9.0)/5 (1.0) 9.02 (3.61–22.55)
63 (10.5)/7 (1.2) 9.08 (4.19–19.65)
19 (9.3)/2 (1.0) 9.41 (2.22–39.87)
145 (9.6)/14 (1.1) 9.10 (5.27–15.72) 9.15 (4.63–18.08)§
0.9988
Subsequent revascularization PCI-S/CABG, n (%) RR (95% CI)
101 (20.7)/30 (6.0) 3.45 (2.34–5.08)
182 (30.3)/53 (8.8) 3.46 (2.61–4.60)
66 (32.2)/7 (3.4) 9.34 (4.39–19.86)
413 (27.2)/107 (7.0) 4.01 (2.93–5.49) 4.46 (2.76–7.22)§
0.1071
NR —
23 (3.8)/21 (3.5) 1.10 (0.62–1.97)
7 (3.4)/12 (58.9) 0.58 (0.23–1.44)
30 (3.7)/33 (4.1) 0.88 (0.48–1.61)
0.2400
NR —
250 (41.7)/132 (21.8)¶ 1.91 (1.60–2.28)
113 (55.1)/30 (14.8)** 3.73 (2.62–5.31)
441 (42.8)/215 (20.8) 2.16 (1.38–3.37)
0.0003
NR —
19 (8.4)/NR —
64 (28.4)/17 (7.6) 3.76 (2.28–6.22)
NR — 78 (34.7)/53 (23.6)# 1.47 (1.09–1.98)
3,051 1,518/1,533 The American Journal of Cardiology (www.AJConline.org)
1,205 600/605 61 ⫾ 10/61 ⫾ 9 77/76 61 ⫾ 12/60 ⫾ 13
Combined
Patients PCI-S/CABG Mean age (PCI-S/CABG) (yrs) Men (PCI-S/CABG) (%) Mean ejection fraction (PCI-S/CABG) (%) Death PCI-S/CABG, n (%) RR (95% CI)
CVA PCI-S/CABG, n (%) RR (95% CI) MACEs PCI-S/CABG, n (%) RR (95% CI)
988 488/500 61 ⫾ 9.2/62 ⫾ 9.5 80/78 57/57
MASS II5
0.0329 * Median. † Range. ‡ Inclusion criteria. § Combined estimate eliminating the SoS trial. 储 Q-wave MI. ¶ Death, nonfatal MI, revascularization, or CVA. # Death, nonfatal Q-wave MI, revascularization, or CVA. ** Death, nonfatal Q-wave MI, or revascularization. CI ⫽ confidence interval; CVA ⫽ cerebrovascular accident; MI ⫽ myocardial infarction; NR ⫽ not reported; RR ⫽ risk ratio.
19.8/17.9 1.01 (0.70–1.46) 22.7/25.9 0.88 (0.60–1.29) 14.0/18.0 0.78 (0.51–1.19) 21.2/15.5 1.36 (1.07–1.73) NR — Angina PCI-S/CABG (%) RR (95% CI)
MASS II5 ERACI II4 ARTS3 SoS2 Variable
Table 1 (continued)
Combined
p Value of Heterogeneity
Coronary Artery Disease/Outcomes of CABG Versus Stenting
1261
ing or very recent myocardial infarctions, and left ventricular ejection fractions ⬍35%, which are clearly different from the characteristics of the 4 other trials. In total, our meta-analysis included data on 3,051 patients (Table 1). Anticoagulation regimens after the procedures were not reported in all trials, but aspirin was used in 80% and 70% of the PCI-S and CABG groups, respectively, during 1 year of follow-up in MASS II.7 Pooled analysis demonstrated no statistically significant differences in death, cardiac death, Q-wave myocardial infarction, cerebrovascular accidents, and angina between PCI-S and CABG. However, PCI-S was associated with statistically significant increases in subsequent PCI, subsequent CABG, subsequent revascularization (PCI or CABG), and MACEs relative to CABG. There was significant trial heterogeneity of death, subsequent PCI, MACEs, and angina. There was no evidence of a significant publication bias, except for subsequent revascularization (p ⫽ 0.0415). To assess the impact of qualitative heterogeneity in trial design on the pooled effect estimate, we performed a sensitivity analysis. Eliminating the SoS trial, with short follow-up (1 to 4 years), did not substantially change the pooled point estimate. Discussion The main limitation of the previous meta-analysis by Mercado et al1 of RCTs of PCI-S versus CABG for multivessel CAD was the relatively short follow-up period, limited to 1 year. The present meta-analysis of long-term follow-up of 4 currently available RCTs demonstrated higher subsequent revascularization and MACEs in PCI-S compared with CABG, reinforcing the results of the previous meta-analysis.1 Insofar as singlevessel (left anterior descending coronary artery) CAD is concerned, a meta-analysis by Aziz et al8 demonstrated that PCI-S was fraught with significantly increased risk for subsequent revascularization and MACEs in comparison with minimally invasive direct CABG. Therefore, for single-vessel and mutivessel CAD, CABG surpasses PCI-S in the reduction of subsequent revascularization and MACEs. 1. Mercado N, Wijns W, Serruys PW, Sigwart U, Flather MD, Stables RH, O’Neill WW, Rodriguez A, Lemos PA, Hueb WA, et al. Oneyear outcomes of coronary artery bypass graft surgery versus percutaneous coronary intervention with multiple stenting for multisystem disease: a meta-analysis of individual patient data from randomized clinical trials. J Thorac Cardiovasc Surg 2005;130:512–519. 2. SoS Investigators. Coronary artery bypass surgery versus percutaneous coronary intervention with stent implantation in patients with multivessel coronary artery disease (the Stent or Surgery trial): a randomised controlled trial. Lancet 2002;360:965–970. 3. Serruys PW, Ong AT, van Herwerden LA, Sousa JE, Jatene A, Bonnier JJ, Schonberger JP, Buller N, Bonser R, Disco C, et al. Five-year outcomes after coronary stenting versus bypass surgery for the treatment of multivessel disease: the final analysis of the Arterial Revascularization Therapies Study (ARTS) randomized trial. J Am Coll Cardiol 2005;46:575–581. 4. Rodriguez AE, Baldi J, Fernandez Pereira C, Navia J, Rodriguez Alemparte M, Delacasa A, Vigo F, Vogel D, O’Neill W, Palacios IF; ERACI II Investigators. Five-year follow-up of the Argentine random-
1262
The American Journal of Cardiology (www.AJConline.org)
ized trial of coronary angioplasty with stenting versus coronary bypass surgery in patients with multiple vessel disease (ERACI II). J Am Coll Cardiol 2005;46:582–588. 5. Hueb W, Lopes NH, Gersh BJ, Soares P, Machado LA, Jatene FB, Oliveira SA, Ramires JA. Five-year follow-up of the Medicine, Angioplasty, or Surgery Study (MASS II): a randomized controlled clinical trial of 3 therapeutic strategies for multivessel coronary artery disease. Circulation 2007;115:1082–1089. 6. Hueb W, Soares PR, Gersh BJ, César LA, Luz PL, Puig LB, Martinez EM, Oliveira SA, Ramires JA. The Medicine, Angioplasty, or Surgery Study (MASS-II): a randomized, controlled clinical trial of three therapeutic strategies for multivessel coronary artery disease: one-year results. J Am Coll Cardiol 2004;43:1743–1751.
7. Morrison DA, Sethi G, Sacks J, Henderson W, Grover F, Sedlis S, Esposito R, Ramanathan K, Weiman D, Saucedo J, et al, for the Investigators of the Department of Veterans Affairs Cooperative Study 385 the Angina With Extremely Serious Operative Mortality Evaluation (AWESOME). Percutaneous coronary intervention versus coronary artery bypass graft surgery for patients with medically refractory myocardial ischemia and risk factors for adverse outcomes with bypass: a multicenter, randomized trial. J Am Coll Cardiol 2001;38:143–149. 8. Aziz O, Rao C, Panesar SS, Jones C, Morris S, Darzi A, Athanasiou T. Meta-analysis of minimally invasive internal thoracic artery bypass versus percutaneous revascularisation for isolated lesions of the left anterior descending artery. BMJ 2007;334:617.