Yonsei Med J.  2011 Nov;52(6):923-932. 10.3349/ymj.2011.52.6.923.

Comparison of Bypass Surgery with Drug-Eluting Stents in Diabetic Patients with Left Main Coronary Stenosis

• Zhao X
• Zhou Y
• Song H
• Guan L
• Zheng G
• Jin Z
• Shi D
• Li Y
• Guo Y
• Shi GP
• Cheng XW

• KMID: 1058811
• DOI: http://doi.org/10.3349/ymj.2011.52.6.923

Abstract

PURPOSE
Several studies have compared the effects of coronary stenting and coronary-artery bypass grafting (CABG) on left main coronary artery (LMCA) disease. However, there are limited data on the long-term outcomes of these two interventions in diabetic patients.
MATERIALS AND METHODS
We evaluated 56 patients with LMCA stenosis who underwent drug-eluting stent (DES) implantation and 116 patients who underwent CABG in a single hospital in China between January 2004 and December 2006. We compared long-term major adverse cardiac events (death; a "serious outcome" composite of death, myocardial infarction, or stroke; and target-vessel revascularization).
RESULTS
In-hospital (30-day) mortality was 0% for the DES group and 3.4% for the CABG group (p=0.31). There was no difference between the two groups in terms of risk of death [hazard ratio for stenting group, 0.49; 95% confidence interval (CI), 0.13-1.63; p=0.55] or risk of serious outcome (hazard ratio for DES group, 1.11; 95% CI, 0.39-1.45; p=0.47). The target-vessel revascularization rate was higher in the DES group than in the CABG group (hazard ratio, 3.67; 95% CI, 1.24-11.06; p=0.018).
CONCLUSION
In this cohort of diabetic patients with LMCA stenosis, there was no difference in composite endpoints between patients receiving DESs and those undergoing CABG. However, stenting was associated with higher rates of target-vessel revascularization than CABG. DES implantation in diabetic patients with LMCA disease was found to be at least as safe as CABG.

Keyword

Left main coronary artery disease; coronary intervention; drug-eluting stent; coronary-artery bypass grafting; diabetes mellitus

MeSH Terms

Angioplasty, Balloon, Coronary/*methods
Coronary Stenosis/*therapy
Diabetes Mellitus
*Drug-Eluting Stents
Female
Humans
Male
Middle Aged
Treatment Outcome

Figure

• 

  Fig. 1 Kaplan-Meier curves of the PCI (n=56) and the CABG (n=116) groups for death, composite risk of serious outcomes, and the rate of target-vessel revascularization (TVR). There were no differences in death and composite risk between the two groups (A and B), whereas the rate of TVR was higher in the PCI group than in the CABG group (C). PCI, percutaneous coronary intervention; CABG, coronary-artery bypass grafting; MI, myocardial infarction.

Reference

1. Caracciolo EA, Davis KB, Sopko G, Kaiser GC, Corley SD, Schaff H, et al. Comparison of surgical and medical group survival in patients with left main equivalent coronary artery disease. Long-term CASS experience. Circulation. 1995. 91:2335–2344.

2. Eagle KA, Guyton RA, Davidoff R, Edwards FH, Ewy GA, Gardner TJ, et al. ACC/AHA 2004 guideline update for coronary artery bypass graft surgery: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery). Circulation. 2004. 110:e340–e437.

3. Colombo A, Chieffo A. Drug-eluting stent update 2007: part III: technique and unapproved/unsettled indications (left main, bifurcations, chronic total occlusions, small vessels and long lesions, saphenous vein grafts, acute myocardial infarctions, and multivessel disease). Circulation. 2007. 116:1424–1432.

4. Serruys PW, Morice MC, Kappetein AP, Colombo A, Holmes DR, Mack MJ, et al. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med. 2009. 360:961–972.

5. Bottner RK, Klein LW. Inverventional Committee of The Society for Cardiovascular Angiography and Interventions. Do the current ACC/AHA guidelines correctly reflect the attitudes and utilization of PCI in patients with unprotected left main coronary artery stenosis? Catheter Cardiovasc Interv. 2005. 64:402–405.

6. Kannel WB, McGee DL. Diabetes and glucose tolerance as risk factors for cardiovascular disease: the Framingham study. Diabetes Care. 1979. 2:120–126.

7. Stamler J, Vaccaro O, Neaton JD, Wentworth D. Diabetes, other risk factors, and 12-yr cardiovascular mortality for men screened in the Multiple Risk Factor Intervention Trial. Diabetes Care. 1993. 16:434–444.

8. Stein B, Weintraub WS, Gebhart SP, Cohen-Bernstein CL, Grosswald R, Liberman HA, et al. Influence of diabetes mellitus on early and late outcome after percutaneous transluminal coronary angioplasty. Circulation. 1995. 91:979–989.

9. Van Belle E, Ketelers R, Bauters C, Périé M, Abolmaali K, Richard F, et al. Patency of percutaneous transluminal coronary angioplasty sites at 6-month angiographic follow-up: a key determinant of survival in diabetics after coronary balloon angioplasty. Circulation. 2001. 103:1218–1224.

10. Park SJ, Kim YH, Lee BK, Lee SW, Lee CW, Hong MK, et al. Sirolimus-eluting stent implantation for unprotected left main coronary artery stenosis: comparison with bare metal stent implantation. J Am Coll Cardiol. 2005. 45:351–356.

11. Genuth S, Alberti KG, Bennett P, Buse J, Defronzo R, Kahn R, et al. Follow-up report on the diagnosis of diabetes mellitus. Diabetes Care. 2003. 26:3160–3167.

12. Park SJ, Hong MK, Lee CW, Kim JJ, Song JK, Kang DH, et al. Elective stenting of unprotected left main coronary artery stenosis: effect of debulking before stenting and intravascular ultrasound guidance. J Am Coll Cardiol. 2001. 38:1054–1060.

13. Park SJ, Lee CW, Kim YH, Lee JH, Hong MK, Kim JJ, et al. Technical feasibility, safety, and clinical outcome of stenting of unprotected left main coronary artery bifurcation narrowing. Am J Cardiol. 2002. 90:374–378.

14. Eagle KA, Guyton RA, Davidoff R, Edwards FH, Ewy GA, Gardner TJ, et al. ACC/AHA 2004 guideline update for coronary artery bypass graft surgery: summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery). J Am Coll Cardiol. 2004. 44:e213–e310.

15. Wang ZJ, Zhou YJ, Liu YY, Yu M, Shi DM, Zhao YX, et al. Obesity and cardiovascular thrombotic events in patients undergoing percutaneous coronary intervention with drug-eluting stents. Heart. 2009. 95:1587–1592.

16. Biondi-Zoccai GG, Giraudi E, Moretti C, Sciuto F, Omedè P, Sillano D, et al. Impact of routine angiographic follow-up after percutaneous coronary drug-eluting stenting for unprotected left main disease: the Turin Registry. Clin Res Cardiol. 2010. 99:235–242.

17. Tu JV, Jaglal SB, Naylor CD. Steering Committee of the Provincial Adult Cardiac Care Network of Ontario. Multicenter validation of a risk index for mortality, intensive care unit stay, and overall hospital length of stay after cardiac surgery. Circulation. 1995. 91:677–684.

18. Hirashiki A, Izawa H, Cheng XW, Unno K, Ohshima S, Murohara T. Dobutamine-induced mechanical alternans is a marker of poor prognosis in idiopathic dilated cardiomyopathy. Clin Exp Pharmacol Physiol. 2010. 37:1004–1009.

19. Cheng CI, Lee FY, Chang JP, Hsueh SK, Hsieh YK, Fang CY, et al. Long-term outcomes of intervention for unprotected left main coronary artery stenosis: coronary stenting vs coronary artery bypass grafting. Circ J. 2009. 73:705–712.

20. Dubois C, Dens J, Sinnaeve P, Belmans A, Van Cleemput J, Mendez M, et al. Results of percutaneous coronary intervention of the unprotected left main coronary artery in 143 patients and comparison of 30-day mortality to results of coronary artery bypass grafting. Am J Cardiol. 2008. 101:75–81.

21. Seung KB, Park DW, Kim YH, Lee SW, Lee CW, Hong MK, et al. Stents versus coronary-artery bypass grafting for left main coronary artery disease. N Engl J Med. 2008. 358:1781–1792.

22. Chaitman BR, Fisher LD, Bourassa MG, Davis K, Rogers WJ, Maynard C, et al. Effect of coronary bypass surgery on survival patterns in subsets of patients with left main coronary artery disease. Report of the Collaborative Study in Coronary Artery Surgery (CASS). Am J Cardiol. 1981. 48:765–777.

23. Eldar M, Schulhoff N, Herz I, Frankel R, Feld H, Shani J. Results of percutaneous transluminal angioplasty of the left main coronary artery. Am J Cardiol. 1991. 68:255–256.

24. O'Keefe JH Jr, Hartzler GO, Rutherford BD, McConahay DR, Johnson WL, Giorgi LV, et al. Left main coronary angioplasty: early and late results of 127 acute and elective procedures. Am J Cardiol. 1989. 64:144–147.

25. Dzavik V, Ghali WA, Norris C, Mitchell LB, Koshal A, Saunders LD, et al. Long-term survival in 11,661 patients with multivessel coronary artery disease in the era of stenting: a report from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) Investigators. Am Heart J. 2001. 142:119–126.

26. Takagi T, Stankovic G, Finci L, Toutouzas K, Chieffo A, Spanos V, et al. Results and long-term predictors of adverse clinical events after elective percutaneous interventions on unprotected left main coronary artery. Circulation. 2002. 106:698–702.

27. Sanmartin M, Baz JA, Claro R, Asorey V, Durán D, Pradas G, et al. Comparison of drug-eluting stents versus surgery for unprotected left main coronary artery disease. Am J Cardiol. 2007. 100:970–973.

28. Brener SJ, Galla JM, Bryant R 3rd, Sabik JF 3rd, Ellis SG. Comparison of percutaneous versus surgical revascularization of severe unprotected left main coronary stenosis in matched patients. Am J Cardiol. 2008. 101:169–172.

29. Silvestri M, Barragan P, Sainsous J, Bayet G, Simeoni JB, Roquebert PO, et al. Unprotected left main coronary artery stenting: immediate and medium-term outcomes of 140 elective procedures. J Am Coll Cardiol. 2000. 35:1543–1550.

30. Hu FB, Tamai H, Kosuga K, Kyo E, Hata T, Okada M, et al. Intravascular ultrasound-guided directional coronary atherectomy for unprotected left main coronary stenoses with distal bifurcation involvement. Am J Cardiol. 2003. 92:936–940.

31. Fröbert O, Lagerqvist B, Carlsson J, Lindbäck J, Stenestrand U, James SK. Differences in restenosis rate with different drug-eluting stents in patients with and without diabetes mellitus: a report from the SCAAR (Swedish Angiography and Angioplasty Registry). J Am Coll Cardiol. 2009. 53:1660–1667.

32. Farkouh ME, Dangas G, Leon MB, Smith C, Nesto R, Buse JB, et al. Design of the Future REvascularization Evaluation in patients with Diabetes mellitus: optimal management of Multivessel disease (FREEDOM) Trial. Am Heart J. 2008. 155:215–223.

33. Park DW, Seung KB, Kim YH, Lee JY, Kim WJ, Kang SJ, et al. Long-term safety and efficacy of stenting versus coronary artery bypass grafting for unprotected left main coronary artery disease: 5-year results from the MAIN-COMPARE (Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary Angioplasty Versus Surgical Revascularization) registry. J Am Coll Cardiol. 2010. 56:117–124.

34. Park DW, Kim YH, Yun SC, Lee JY, Kim WJ, Kang SJ, et al. Long-term outcomes after stenting versus coronary artery bypass grafting for unprotected left main coronary artery disease: 10-year results of bare-metal stents and 5-year results of drug-eluting stents from the ASAN-MAIN (ASAN Medical Center-Left MAIN Revascularization) Registry. J Am Coll Cardiol. 2010. 56:1366–1375.

35. Morice MC, Serruys PW, Kappetein AP, Feldman TE, Ståhle E, Colombo A, et al. Outcomes in patients with de novo left main disease treated with either percutaneous coronary intervention using paclitaxel-eluting stents or coronary artery bypass graft treatment in the Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery (SYNTAX) trial. Circulation. 2010. 121:2645–2653.

36. Kim YH, Park DW, Kim WJ, Lee JY, Yun SC, Kang SJ, et al. Impact of the extent of coronary artery disease on outcomes after revascularization for unprotected left main coronary artery stenosis. J Am Coll Cardiol. 2010. 55:2544–2552.

37. Sheiban I, Garrone P, Sillano D, Biondi-Zoccai G, Sciuto F, Omedè P, et al. Impact of diabetes mellitus on early and long-term results of percutaneous drug-eluting stent implantation for unprotected left main coronary disease. J Cardiovasc Med (Hagerstown). 2008. 9:1246–1253.

38. Meliga E, Garcia-Garcia HM, Valgimigli M, Chieffo A, Biondi-Zoccai G, Maree AO, et al. Diabetic patients treated for unprotected left main coronary artery disease with drug eluting stents: a 3-year clinical outcome study. The diabetes and drug eluting stent for LeFT main registry (D-DELFT). EuroIntervention. 2008. 4:77–83.

39. Banning AP, Westaby S, Morice MC, Kappetein AP, Mohr FW, Berti S, et al. Diabetic and nondiabetic patients with left main and/or 3-vessel coronary artery disease: comparison of outcomes with cardiac surgery and paclitaxel-eluting stents. J Am Coll Cardiol. 2010. 55:1067–1075.

40. Kim WJ, Park DW, Yun SC, Lee JY, Lee SW, Kim YH, et al. Impact of diabetes mellitus on the treatment effect of percutaneous or surgical revascularization for patients with unprotected left main coronary artery disease: a subgroup analysis of the MAIN-COMPARE study. JACC Cardiovasc Interv. 2009. 2:956–963.

41. Sousa JE, Costa MA, Abizaid A, Feres F, Seixas AC, Tanajura LF, et al. Four-year angiographic and intravascular ultrasound follow-up of patients treated with sirolimus-eluting stents. Circulation. 2005. 111:2326–2329.

42. Kuntz RE. Importance of considering atherosclerosis progression when choosing a coronary revascularization strategy: the diabetes-percutaneous transluminal coronary angioplasty dilemma. Circulation. 1999. 99:847–851.

43. Lee MS, Kapoor N, Jamal F, Czer L, Aragon J, Forrester J, et al. Comparison of coronary artery bypass surgery with percutaneous coronary intervention with drug-eluting stents for unprotected left main coronary artery disease. J Am Coll Cardiol. 2006. 47:864–870.

44. Chieffo A, Morici N, Maisano F, Bonizzoni E, Cosgrave J, Montorfano M, et al. Percutaneous treatment with drug-eluting stent implantation versus bypass surgery for unprotected left main stenosis: a single-center experience. Circulation. 2006. 113:2542–2547.