Isolated Disease of the Proximal Left Anterior Descending ArteryComparing 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
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Abstract
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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
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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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Percutaneous coronary interventions (PCI) (with or without stents) and coronary artery bypass graft (CABG) surgery are the alternative approaches to revascularization for patients with isolated stenosis of the proximal left anterior descending (LAD) (1,2). Some studies have reported fewer repeat revascularization procedures and more freedom from angina among patients with isolated LAD stenosis who have received CABG rather than PCI (3,4). However, procedural morbidity such as stroke is reported to be higher among CABG recipients (5). Some investigators argue that advances in CABG procedures, such as the use of minimally invasive direct coronary artery bypass (MIDCAB) (which was developed initially to treat proximal LAD stenosis), may decrease procedural morbidity with similar graft patency rates compared with traditional CABG (6). However, others suggest that the technical challenge of MIDCAB may lead to poor or improper anastomosis, acute graft failure, and need for full sternotomy (5,7). In light of these conflicting views, there is no clear consensus as to the best coronary revascularization procedure for patients with single-vessel proximal LAD lesions.
Prior systematic reviews of trials comparing CABG and PCI have not specifically reported outcomes for patients with single-vessel disease of the proximal LAD (8–13). Additionally, since the publication of these reviews, new trial data from patients with proximal LAD disease have become available (5,14–19). We therefore reviewed current data on outcomes after random assignment to PCI or CABG among patients with single-vessel disease of the proximal LAD.
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Methods
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Search strategy.
We identified randomized controlled trials (RCTs) that compared outcomes for patients with single-vessel proximal LAD disease assigned to either PCI or CABG. We performed individualized searches of relevant databases (MEDLINE, EMBASE, and Cochrane from 1966 to 2006) with terms such as angioplasty, coronary, and coronary artery bypass surgery (complete search strategies are available elsewhere [12]). We also manually searched reference lists of included articles and the bibliographies of expert advisors. We did not limit searches to the English language.
Study selection.
We searched for RCTs that compared PCI and CABG in patients with angiographically proven single-vessel disease of the proximal LAD. Trials were included without limitation to subject population, year, or type of surgical or percutaneous intervention. We excluded RCTs comparing only 2 or more PCI technologies or 2 or more CABG technologies. The trials included a variety of PCI technologies (i.e., balloon angioplasty, with or without stents) and a variety of surgical procedures (i.e., traditional on-pump and off-pump bypass procedures, and minimally invasive procedures).
Data extraction.
We abstracted the following data from the included trials: study design; setting; population characteristics; detailed information about the PCI and CABG interventions performed; numbers of patients screened, eligible, enrolled, and lost to follow-up; method of outcome ascertainment; and results for each outcome. The outcomes of interest included both procedural outcomes (e.g., procedural stroke, length of stay) and long-term outcomes (e.g., survival, angina relief, repeat revascularization, quality of life). Two authors independently reviewed the title, abstract, and full text of each included study. We resolved abstraction conflicts by re-review and discussion.
Quality assessment of individual studies.
We used predefined criteria to assess the quality of included trials as good, fair, or poor (20–22). These quality criteria included the method of randomization, the use of intention-to-treat analysis, the report of dropout rates, and the extent to which valid outcomes were described.
Data synthesis.
We computed summary risk differences and summary odds ratios for each outcome of interest using random effects models. Because the results were consistent between these methods, we present summary risk differences because several of the outcomes of interest (e.g., procedural mortality) were rare events and the risk difference is a more stable outcome metric than odds ratios under these circumstances (23,24).
We assessed heterogeneity for summary effects by calculating the chi-square and I2 statistics (25) and considered I2 statistics in excess of 50% to indicate heterogeneity. We sought evidence of publication bias by evaluating the association between the sample size of a study and the likelihood of that study reporting statistically significant outcomes by visual inspection of funnel plots. We also performed sensitivity analyses by evaluating the effects of individual studies on reported summary effects by removing each study individually.
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Results
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Our searches for RCTs comparing the efficacy of PCI and CABG yielded 1,695 potentially relevant articles, of which 204 articles merited full-text review. A total of 17 articles reporting on 9 RCTs met our inclusion criteria (Fig. 1).
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Figure 1 Search Results
The number of citations retrieved from the literature searches and the rationale for inclusion and exclusion for each citation. CABG = coronary artery bypass graft; CAD = coronary artery disease; PCI = percutaneous coronary intervention; RCT = randomized controlled trial.
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Description of the RCTs.
The 9 RCTs of patients with single-vessel disease of the proximal LAD artery enrolled 1,210 patients (633 received PCI and 577 received CABG) (Table 1). Seven of the 9 trials were single-center studies, and most were conducted in Europe. The early studies (patient entry 1987 to 1993) used balloon angioplasty as the PCI technique (1,3,4,26), and the recent studies (1994 to 2002) used stents as the PCI technique (5,14–19,27–32). The early studies used traditional CABG, whereas the more recent studies used MIDCAB and off-pump techniques (5,15–18). Although there were some differences in the inclusion criteria of the RCTs, all 9 trials limited entry to patients with single-vessel disease of the proximal LAD.
The mean age of trial participants ranged from 53 to 63 years. Roughly 20% had diabetes, and more than half had hypertension and/or hyperlipidemia (Table 2). The proportion of women included in the trials ranged from 17% to 36%. The prevalence of heart failure was low, and left ventricular function was generally well preserved.
Quality of the randomized controlled trials.
The quality of most trials was high, and 7 trials received a grade of good because they clearly explained their randomization methods, their dropout rates were low, and they performed intention-to-treat analyses. Because it was not clear that there was concealment of allocation or intention-to-treat and some data were obtained via a retrospective review of charts, the Seoul-Kim (18) trial received a fair grade. We assigned a grade of poor to the Seoul-Hong (17) trial because, in addition to the fact that it was a small trial with very short follow-up (6 months), it may not have been truly randomized, as evidenced by the imbalance between the number of patients assigned to PCI (119) and to CABG (70). Neither the investigators nor the journal editor responded to requests for clarification of the method of randomization. We performed sensitivity analyses by removing the Seoul-Hong trial from our main outcome analysis, without any substantial change in our results. The Seoul-Hong trial is the only included trial that compared PCI using drug-eluting stents (17).
Short-term/procedural outcomes.
Survival
We defined short-term/procedural complications as those occurring within the first 30 days of the revascularization procedure. Procedural survival was above 99% for both procedures (Table 3). When data from all trials were combined, the absolute difference in procedural survival did not differ significantly between procedures (risk difference: 0.3%, 95% confidence interval [CI]: –0.9% to +1.4%) (Fig. 2). We performed separate analyses for the patients who received MIDCAB and those that received traditional CABG, and found no differences in procedural survival between PCI and CABG—regardless of the specific surgical technique performed. Similarly, we found no difference in comparative procedural survival between MIDCAB or off-pump trials compared with PCI at 1 month. There was no substantial evidence for statistical heterogeneity or publication bias.
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Figure 2 Procedural Survival in Balloon Angioplasty or Stent Trials Versus CABG
A comparison of absolute differences in procedural survival in the PCI and CABG groups in each of the trials. SVD = single-vessel disease; other abbreviations as in Figure 1.
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Other outcomes
Procedural strokes were also relatively rare: about 0.5% for both procedures. There was no difference in the absolute rate of procedural stroke (reported by 6 trials) between PCI and CABG (absolute risk difference: 0.2%, 95% CI: –1.2% to +1.6%).
In all 5 studies that reported length of stay (Table 4), patients undergoing CABG consistently spent more time in the hospital (range: 4.5 to 10.1 days) than those receiving PCI (range: 2.3 to 6.1 days) (absolute difference = 3.2 days, 95% CI: 2.3 to 4.1 days, p < 0.0001).
The summary rate of procedural myocardial infarction was reported by all studies and did not differ significantly between PCI and CABG: absolute risk difference = –0.8%; 95% CI: –2.6% to +0.9%. It is important to note that the definition of myocardial infarction varied among studies, and post-procedure serial monitoring of electrocardiograms and serum biomarker levels was not routine, so that ascertainment of procedural myocardial infarctions may not have been uniform or complete.
The AMIST (Angioplasty versus Minimally Invasive Surgery Trial) (14) and SIMA (Stenting versus Internal Mammary Artery) (19) trials reported differences in rates of procedural arrhythmias, and both found an increased risk of events with CABG than with PCI. None of the patients in the PCI arms of either trial experienced any arrhythmias, whereas 19% of CABG recipients experienced atrial fibrillation and approximately 2% had a ventricular arrhythmia.
In the 3 studies that reported procedural bleeding, more CABG-assigned patients required transfusions than did PCI-assigned patients (Table 5); however, the total number of patients requiring transfusion was small, and the difference in procedural bleeding was not significant.
Long-term outcomes.
Survival
Overall survival among CABG-assigned patients was 97.9% at 1 year and 92.8% at 5 years. Overall survival among PCI-assigned patients was 99.7% at 1 year and 90.6% at 5 years. The combined data from all trials showed no statistically significant difference in overall survival in either the first or fifth year post-procedure for PCI and CABG. There was no substantial evidence for statistical heterogeneity or publication bias.
Survival did not differ between PCI and CABG for either balloon angioplasty or stents. At 1 year, survival in studies using balloon angioplasty was 1% greater for CABG recipients (95% CI: –5% to +2%), but the difference was not statistically significant. In trials that used stents, the risk difference (0.1% favoring PCI) also was not statistically significant (95% CI: –4% to +4%).
In addition to reporting overall mortality, 3 studies reported cardiovascular mortality at 5 years (the MASS [Medicine, Angioplasty or Surgery Study] [1], Leipzig [5], Lausanne [3]), but none reported significant differences between the procedures.
Other outcomes
Angina relief was significantly greater 1 year after CABG (absolute rate: 95.5%) than 1 year after PCI (absolute rate: 84.6%) in the 4 trials that reported this outcome (risk difference = 7.9%, 95% CI: 1.9% to 14.0%, p = 0.01). Similarly, angina relief remained significantly greater 5 years after CABG (absolute rate: 84.2%) than 5 years after PCI (absolute rate: 75.6%) in the 2 trials that reported this outcome (risk difference = 8.8%, 95% CI: 1.8% to 15.8%).
The rate of repeat revascularization was significantly greater after PCI (19.5%) than after CABG (4%) in the 2 trials that reported this at 1 year (risk difference = 14.4%, 95% CI: –6.1% to 22.6%, p = 0.001,). The 3 trials that reported revascularization rates at 5 years also reported reduced revascularization after CABG (summary rates 33.5% for PCI vs. 7.3% for CABG; p < 0.0001, risk difference = 26.7%, 95% CI: 20.1% to 33.3%) (Fig. 3).
Data on quality of life were collected by only 2 trials with a maximum follow-up of 15 months (Table 6). The measures chosen included the SF-36, Seattle Angina Questionnaire, and the EuroQol. No significant differences were reported between PCI and CABG recipients.
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Discussion
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This meta-analysis of randomized controlled trials comparing PCI and CABG in patients with single-vessel disease of the proximal LAD who were eligible for both procedures had 3 key findings. First, there was no difference in survival at any time point between PCI and CABG recipients. Second, within the first 30 days of the procedure, there was no difference in the rates of stroke or myocardial infarction, but CABG patients were more likely to require transfusions, have arrhythmias, and require longer hospital stays. Third, there was a much lower rate of repeat revascularization and higher rate angina relief in patients undergoing CABG than PCI.
The finding of equivalent survival between CABG and PCI in patients with isolated LAD disease parallels other recent analyses of patients with other types of coronary artery disease receiving either revascularization procedure (33). Two major clinical registries have reported long-term survival for patients with single-vessel disease (34,35). These registries clearly suggest that most patients with single-vessel disease received PCI, and most patients with more extensive disease received CABG. In the Duke University Medical Center registry overall, 2,924 patients were treated by angioplasty and 3,890 patients underwent bypass surgery (34). The adjusted 5-year survival in patients with single-vessel, proximal LAD stenosis of 95% was 0.89 when treated with CABG and 0.88 when treated with PCI. In the New York registry overall, 29,930 patients underwent angioplasty and 29,646 patients underwent bypass surgery, of which 9,998 patients had single-vessel LAD angioplasty and 2,070 patients had single-vessel LAD bypass (35). The adjusted 3-year survival for patients with proximal LAD disease was 96.6% for CABG versus 95.2% for PCI (p = 0.01). Interestingly, we found no evidence that newer PCI technologies such as the use of bare-metal stents conferred a survival benefit over CABG. Similarly, advances in surgical techniques such as the use MIDCAB or off pump did not result in greater survival benefit than PCI. However, because there has been only 1 small trial of PCI versus CABG used drug-eluting stents (17), further clinical trials are needed to address the comparative efficacy of PCI and CABG for patients with isolated LAD lesions. Recent safety concerns about drug-coated stents emphasize the need for extended follow-up and trials large enough to detect clinically meaningful differences in outcomes. Furthermore, although longer follow-up will be required to measure the impact of saphenous vein bypass graft disease on comparative outcomes, the procedural risk of CABG in large registries has also declined progressively over time, indicating that both CABG and PCI methods continue to evolve.
Prior reviews of patients with a broad spectrum of coronary artery disease (not just patients with single-vessel disease) have shown that the rate of procedural stroke was higher after CABG (1.2%) than after PCI (0.6%) (12,13). Our finding that the rate of procedural stroke was equivalent for PCI and CABG likely reflects the limited nature of both coronary and cerebrovascular disease in this review.
The finding that CABG was associated with improved angina relief and decreased need for revascularization supports the finding of prior systematic reviews (12,13). It is uncertain whether the greater angina relief seen was attributable to more complete initial revascularization with surgery or because of restenosis after PCI.
Our analysis had several key limitations. First, given the small number of studies available for review, our analysis may be underpowered to detect differences in clinical outcomes and adverse events. Second, the generalizability of our results reflects the inclusion criteria of the RCTs. Namely, the trials generally excluded patients over the age of 75 years, with acute myocardial infarction, or severe left ventricular systolic dysfunction, and the proportion of women included in the trials ranged from 17% to 36%; thus, our conclusions about the comparative efficacy of PCI and CABG is limited for these patients. In addition, many studies excluded technically difficult lesions for PCI such as LAD bifurcation lesions, again limiting generalizability. Also, the included trials did not report specific outcomes by key subgroups (e.g., by race/ethnicity, by comorbidities), limiting our ability to evaluate the comparative efficacy of PCI and CABG by these critical subgroups. Although both the exact location and severity of a proximal LAD stenosis relate to prognosis, few of these trials strictly defined proximal LAD by these criteria prospectively.
The combined comparative evidence on PCI and CABG for isolated LAD disease suggests that because there is no significant difference in mortality, other factors such as patient preference or hospital or provider experience as well as anatomic variables (LAD diameter, lesion length, side branch involvement, ostial disease, calcification, and so on) should weigh heavily in the treatment decision. Future studies should evaluate the extent to which the comparative efficacy of PCI and CABG might be affected by other key patient characteristics such as age, gender, and comorbidities to provide more patient-specific data to inform the treatment decisions of patients and their clinicians.
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Acknowledgments
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This meta-analysis is based on research conducted by the Stanford-UCSF Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, Maryland (Contract No. 290-02-0017). We thank Ingram Olkin for his statistical guidance. We are grateful to Chris Stave for help with the literature searches.
* Reprint requests and correspondence: Dr. John R. Kapoor, Division of Cardiology, 300 Pasteur Drive, Stanford, California 94305 (Email: jkapoor{at}stanford.edu).
Manuscript received May 20, 2008;
revised manuscript received July 10, 2008,
accepted July 27, 2008.
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REFERENCES
|
|---|
- Hueb WA, Bellotti G, de Oliveira SA, et al. The Medicine, Angioplasty or Surgery Study (MASS): a prospective, randomized trial of medical therapy, balloon angioplasty or bypass surgery for single proximal left anterior descending artery stenoses J Am Coll Cardiol 1995;26:1600-1605.[Abstract]
- Parisi AF, Folland ED, Hartigan P. A comparison of angioplasty with medical therapy in the treatment of single-vessel coronary artery disease. Veterans Affairs ACME Investigators. N Engl J Med 1992;326:10-16.[Abstract]
- Goy JJ, Eeckhout E, Burnand B, et al. Coronary angioplasty versus left internal mammary artery grafting for isolated proximal left anterior descending artery stenosis Lancet 1994;343:1449-1453.[CrossRef][Web of Science][Medline]
- Goy JJ, Eeckhout E, Moret C, et al. Five-year outcome in patients with isolated proximal left anterior descending coronary artery stenosis treated by angioplasty or left internal mammary artery grafting. A prospective trial. Circulation 1999;99:3255-3259.[Abstract/Free Full Text]
- Diegeler A, Thiele H, Falk V, et al. Comparison of stenting with minimally invasive bypass surgery for stenosis of the left anterior descending coronary artery N Engl J Med 2002;347:561-566.[Abstract/Free Full Text]
- Mack MJ, Magovern JA, Acuff TA, et al. Results of graft patency by immediate angiography in minimally invasive coronary artery surgery Ann Thorac Surg 1999;68:383-389discussion 389–90.[Abstract/Free Full Text]
- Calafiore AM, Di Giammarco G, Teodori G, et al. Midterm results after minimally invasive coronary surgery (LAST operation) J Thorac Cardiovasc Surg 1998;115:763-771.[Abstract/Free Full Text]
- Sim I, Gupta M, McDonald K, Bourassa MG, Hlatky MA. A meta-analysis of randomized trials comparing coronary artery bypass grafting with percutaneous transluminal coronary angioplasty in multivessel coronary artery disease Am J Cardiol 1995;76:1025-1029.[CrossRef][Web of Science][Medline]
- Pocock SJ, Henderson RA, Rickards AF, et al. Meta-analysis of randomised trials comparing coronary angioplasty with bypass surgery Lancet 1995;346:1184-1189.[CrossRef][Web of Science][Medline]
- Hoffman SN, TenBrook JA, Wolf MP, Pauker SG, Salem DN, Wong JB. A meta-analysis of randomized controlled trials comparing coronary artery bypass graft with percutaneous transluminal coronary angioplasty: one- to eight-year outcomes J Am Coll Cardiol 2003;41:1293-1304.[Abstract/Free Full Text]
- Mercado N, Wijns W, Serruys PW, et al. One-year 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.[Abstract/Free Full Text]
- Bravata DM, McDonald KM, Gienger AL, et al. Comparative effectiveness of percutaneous coronary interventions and coronary artery bypass grafting for coronary artery disease. Comparative Effectiveness Review No. 9. (Prepared by Stanford-UCSF Evidence-based Practice Center under Contract No. 290-02-0017). Rockville, MD: Agency for Healthcare Research and Quality; October 2007.
- Bravata DM, Gienger AL, McDonald KM, et al. Systematic review: the comparative effectiveness of percutaneous coronary interventions and coronary artery bypass graft surgery Ann Intern Med 2007;147:703-716.[Abstract/Free Full Text]
- Reeves BC, Angelini GD, Bryan AJ, et al. A multi-centre randomised controlled trial of minimally invasive direct coronary bypass grafting versus percutaneous transluminal coronary angioplasty with stenting for proximal stenosis of the left anterior descending coronary artery Health Technol Assess 2004;8:1-43.[Web of Science][Medline]
- Drenth DJ, Veeger NJGM, Winter JB, et al. A prospective randomized trial comparing stenting with off-pump coronary surgery for high-grade stenosis in the proximal left anterior descending coronary artery: three-year follow-up J Am Coll Cardiol 2002;40:1955-1960.[Abstract/Free Full Text]
- Cisowski M, Drzewiecki J, Drzewiecka-Gerber A, et al. Primary stenting versus MIDCAB: preliminary report—comparison of two methods of revascularization in single left anterior descending coronary artery stenosis Ann Thorac Surg 2002;74:S1334-S1339.[Abstract/Free Full Text]
- Hong SJ, Lim D-S, Seo HS, et al. Percutaneous coronary intervention with drug-eluting stent implantation vs. minimally invasive direct coronary artery bypass (MIDCAB) in patients with left anterior descending coronary artery stenosis Catheter Cardiovasc Interv 2005;64:75-81.[CrossRef][Web of Science][Medline]
- Kim JW, Lim DS, Sun K, Shim WJ, Rho YM. Stenting or MIDCAB using ministernotomy for revascularization of proximal left anterior descending artery? Int J Cardiol 2005;99:437-441.[CrossRef][Web of Science][Medline]
- Goy JJ, Kaufmann U, Goy-Eggenberger D, et al. A prospective randomized trial comparing stenting to internal mammary artery grafting for proximal, isolated de novo left anterior coronary artery stenosis: the SIMA trial Mayo Clin Proc 2000;75:1116-1123.[Abstract]
- Altman DG, Schulz KF, Moher D, et al. The revised CONSORT statement for reporting randomized trials: explanation and elaboration Ann Intern Med 2001;134:663-694.[Abstract/Free Full Text]
- Moher D, Schulz KF, Altman D. The CONSORT statement: revised recommendations for improving the quality of reports of parallel-group randomized trials JAMA 2001;285:1987-1991.[Abstract/Free Full Text]
- West SL, King V, Carey TS, et al. Systems to Rate the Strength of Scientific Evidence. Evidence Report, Technology Assessment No. 47. AHRQ Publication No. 02-E016Rockville, MD: Agency for Healthcare Research and Quality; 2002.
- Cooper H, Hedges L. The Handbook of Research SynthesisNew York, NY: Russell Sage Foundation; 1994.
- Engels EA, Schmid CH, Terrin N, Olkin I, Lau J. Heterogeneity and statistical significance in meta-analysis: an empirical study of 125 meta-analyses Stat Med 2000;19:1707-1728.[CrossRef][Web of Science][Medline]
- Review Manager (RevMan). Version 4.2 for Windows edition. Copenhagen: The Nordic Cochrane Center, The Cochrane Collaboration; 2003.
- Hueb WA, Soares PR, Almeida De Oliveira S, et al. Five-year follow-up of the Medicine, Angioplasty, or Surgery Study (MASS): a prospective, randomized trial of medical therapy, balloon angioplasty, or bypass surgery for single proximal left anterior descending coronary artery stenosis Circulation 1999;100:II107-II113.[Medline]
- Drenth DJ, Veeger NJGM, Grandjean JG, Mariani MA, van Boven AJ, Boonstra PW. Isolated high-grade lesion of the proximal LAD: a stent or off-pump LIMA? Eur J Cardiothorac Surg 2004;25:567-571.[Abstract/Free Full Text]
- Drenth DJ, Veeger NJGM, Middel B, Zijlstra F, Boonstra PW. Comparison of late (four years) functional health status between percutaneous transluminal angioplasty intervention and off-pump left internal mammary artery bypass grafting for isolated high-grade narrowing of the proximal left anterior descending coronary artery Am J Cardiol 2004;94:1414-1417.[CrossRef][Web of Science][Medline]
- Drenth DJ, Winter JB, Veeger NJGM, et al. Minimally invasive coronary artery bypass grafting versus percutaneous transluminal coronary angioplasty with stenting in isolated high-grade stenosis of the proximal left anterior descending coronary artery: six months' angiographic and clinical follow-up of a prospective randomized study J Thorac Cardiovasc Surg 2002;124:130-135.[Abstract/Free Full Text]
- Diegeler A, Spyrantis N, Matin M, et al. The revival of surgical treatment for isolated proximal high grade LAD lesions by minimally invasive coronary artery bypass grafting Eur J Cardiothorac Surg 2000;17:501-504.[Abstract/Free Full Text]
- Thiele H, Oettel S, Jacobs S, et al. Comparison of bare-metal stenting with minimally invasive bypass surgery for stenosis of the left anterior descending coronary artery: a 5-year follow-up Circulation 2005;112:3445-3450.[Abstract/Free Full Text]
- Cisowski M, Drzewiecka-Gerber A, Ulczok R, et al. Primary direct stenting versus endoscopic atraumatic coronary artery bypass surgery in patients with proximal stenosis of the left anterior descending coronary artery—a prospective, randomised study Kardiol Pol 2004;61:253-261discussion 262–4.[Medline]
- Davies S, Geppert J, McClellan M, McDonald K, Romano P, Shojania K, et al. Refinement of the HCUP Quality IndicatorsAgency for Health Care Research and Quality EPCTM Evidence Report/Technology Assessment. Review #4. Internet Publication: December 2001. Agency for Healthcare Research and Quality, Rockville, MD http://www.ahrq.gov/data/hcup/qirefine.htm 2004Accessed December, 2001.
- Jones RH, Kesler K, Phillips 3rd HR, et al. Long-term survival benefits of coronary artery bypass grafting and percutaneous transluminal angioplasty in patients with coronary artery disease J Thorac Cardiovasc Surg 1996;111:1013-1025.[Abstract/Free Full Text]
- Hannan EL, Racz MJ, McCallister BD, et al. A comparison of three-year survival after coronary artery bypass graft surgery and percutaneous transluminal coronary angioplasty J Am Coll Cardiol 1999;33:63-72.[Abstract/Free Full Text]
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Abstract
Methods