Greater Benefit Seen With Multiple Arterial CABG Versus PCI in Long Term

September 25, 2015—Findings from a study that sought to investigate longer-term outcomes including the potential added advantage of multiarterial coronary artery bypass graft (MA-CABG) compared with percutaneous coronary intervention (PCI) were published by Robert H. Habib, PhD, et al in the Journal of the American College of Cardiology (2015;66:1417–1427).  

Treatment of multivessel coronary artery disease with traditional single-arterial coronary artery bypass graft (SA-CABG) has previously been associated with superior intermediate-term survival and reintervention compared with PCI using either bare metal stents (BMS) or drug-eluting stents (DES). This single-center study was led by Robert F. Tranbaugh, MD, who is Chief of Cardiac Surgery at Mount Sinai Beth Israel in New York, New York.

As summarized in JACC, the study was composed of 8,402 patients receiving primary revascularization for multivessel coronary artery disease: 2,207 BMS-PCI (age 66.6 ± 11.9 years); 2,381 DES-PCI (age 65.9 ± 11.7 years); 2,289 SA-CABG (age 69.3 ± 9 years); and 1,525 MA-CABG (age 58.3 ± 8.7 years). Patients with myocardial infarction within 24 hours, shock, or left main stents were excluded. Kaplan-Meier analysis and Cox regression were used to separately compare 9-year all-cause mortality and unplanned reintervention for BMS-PCI and DES-PCI to respective propensity-matched SA-CABG and MA-CABG cohorts.

The investigators reported that BMS-PCI was associated with worse survival than SA-CABG, especially from 0 to 7 years (P = .015) and to a greater extent than MA-CABG (9-year follow-up: 76.3% vs 86.9%; P < .001). The surgery-to-BMS-PCI hazard ratios (HR) were as follows: versus SA-CABG, HR: 0.87; and versus MA-CABG, HR: 0.38. DES-PCI showed similar survival to SA-CABG except for a modest 0 to 3 years surgery advantage (HR: 1.06; P = .615). Compared with MA-CABG, DES-PCI exhibited worse survival at 5 years (86.3% vs 95.6%) and 9 years (82.8% vs 89.8%; HR: 0.45; P < .001). Reintervention was substantially worse with PCI for all comparisons (all P < .001).

The investigators concluded that multiarterial surgical revascularization, compared with either BMS-PCI or DES-PCI, resulted in substantially enhanced rates of death and reintervention-free survival. Accordingly, MA-CABG represents the optimal therapy for multivessel coronary artery disease and should be enthusiastically adopted by multidisciplinary heart teams as the best evidence-based therapy.

An audio editorial available online with the study by JACC Editor-in-Chief Valentin Fuster, MD, discusses the strengths of the study, as well as some limitations  that are pointed out by Robert A. Guyton, MD, in the accompanying commentary, “Multiple Arterial Coronary Bypass Grafting: Likely Better, But Not Yet a Mandate” in JACC (2015;66:1428–1430).