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Isolated Disease of the Proximal Left Anterior Descending Artery

Comparing the Effectiveness of Percutaneous Coronary Interventions and Coronary Artery Bypass Surgery

John R. Kapoor, MD, PhD^_*,_*, Allison L. Gienger, BA, Reza Ardehali, MD, PhD^_*, Robin Varghese, MD, MS, Marco V. Perez, MD^_*, Vandana Sundaram, MPH^,, Kathryn M. McDonald, MM, Douglas K. Owens, MD, MS^,, Mark A. Hlatky, MD^_*,, Dena M. Bravata, MD, MS

^_* Department of Cardiology, Stanford University School of Medicine, Stanford, California
Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, California
Department of Cardiovascular Surgery, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada
Veterans Affairs Palo Alto Health Care System, Palo Alto, California

^_* Reprint requests and correspondence: Dr. John R. Kapoor, Division of Cardiology, 300 Pasteur Drive, Stanford, California 94305 (Email: jkapoor{at}stanford.edu).

Objectives: This study sought to systematically compare the effectiveness of percutaneous coronary intervention and coronary artery bypass surgery in patients with single-vessel disease of the proximal left anterior descending (LAD) coronary artery.

Background: It is uncertain whether percutaneous coronary interventions (PCI) or coronary artery bypass grafting (CABG) surgery provides better clinical outcomes among patients with single-vessel disease of the proximal LAD.

Methods: We searched relevant databases (MEDLINE, EMBASE, and Cochrane from 1966 to 2006) to identify randomized controlled trials that compared outcomes for patients with single-vessel proximal LAD assigned to either PCI or CABG.

Results: We identified 9 randomized controlled trials that enrolled a total of 1,210 patients (633 received PCI and 577 received CABG). There were no differences in survival at 30 days, 1 year, or 5 years, nor were there differences in the rates of procedural strokes or myocardial infarctions, whereas the rate of repeat revascularization was significantly less after CABG than after PCI (at 1 year: 7.3% vs. 19.5%; at 5 years: 7.3% vs. 33.5%). Angina relief was significantly greater after CABG than after PCI (at 1 year: 95.5% vs. 84.6%; at 5 years: 84.2% vs. 75.6%). Patients undergoing CABG spent 3.2 more days in the hospital than those receiving PCI (95% confidence interval: 2.3 to 4.1 days, p < 0.0001), required more transfusions, and were more likely to have arrhythmias immediately post-procedure.

Conclusions: In patients with single-vessel, proximal LAD disease, survival was similar in CABG-assigned and PCI-assigned patients; CABG was significantly more effective in relieving angina and led to fewer repeat revascularizations.

Key Words: revascularization • surgery • angioplasty • stents • angina

Abbreviations and Acronyms   CABG = coronary artery bypass grafting   CI = confidence interval   LAD = left anterior descending   MIDCAB = minimally invasive direct coronary artery bypass   PCI = percutaneous coronary interventions   RCT = randomized controlled trial

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