Author + information
- Ram Belbase1,
- Arun Kanmanthareddy1,
- Michael White1,
- Michael Del Core1,
- Mark Jeff Holmberg1,
- Venkata Alla1 and
- Jeff Carstens2
Goal of this study was to synthesize the evidence comparing short as well as long term outcomes of percutaneous coronary intervention (PCI) with the coronary artery bypass surgery (CABG) in patients with unprotected left main (UPLM) coronary artery stenosis.
Increasing number of patients with unprotected left main coronary artery disease are being considered for percutaneous coronary intervention. Patients with multiple, severe co morbidities with high risk of surgery do not have many other options except being on optimal medical therapy or possible PCI. Recent randomized trials comparing the above treatment options have shown conflicting results.
We performed meta-analysis of randomized clinical trials (RCT) and observational studies reporting early as well as late outcomes after PCI and CABG for UPML stenosis. Studies published between January of 2000 and October 2016 were included.
Six randomized trials and twenty-four observational studies with 22,936 patients were included in the meta-analysis. There was no significant difference between PCI Vs CABG in all-cause mortality at 30 days with odds ratio(OR) of 0.58 and 95% confidence interval (CI) of 0.28 to 1.19, at one year with OR of 0.79 (CI 0.64-0.99) and at long term (average of three years) with OR of 0.98 (CI 0.84-1.15). Similarly, no difference noted for myocardial infarction (MI) at 30 days with OR of 0.97 (CI: 0.60-1.58), one year with OR of 0.99 (CI:0.71- 1.38) and at long term with) OR 1.46 (CI: 0.90-2.37). However, rates of stroke were better with PCI at all time periods: 30 days OR 0.35 (CI: 0.19-0.66), one-year OR 0.26(CI:0.13-0.51) and long term OR of 0.62(CI:0.51-0.74). Major adverse cardiac and cerebrovascular events(MACCE) were better with PCI with OR of 0.58(CI:0.38-0.90) at 30 days mainly due to higher rates of stroke with CABG. But both one-year OR 1.36(CI:1.13-1.64) and long term OR 1.24(CI:1.05-1.48) MACCE outcomes were lower with CABG primarily driven by increased need for both total revascularization OR 2.18(CI:1.57-3.02) and target vessel revascularization (TVR) with OR of 3.10(CI:2.06-4.66) in long term with PCI.
Our analysis demonstrates PCI and CABG have comparable mortality and MI rates in patients with UPLM stenosis. Risk of stroke is lower with PCI but overall MACCE rates are higher with PCI, driven by higher need for total as well as target vessel revascularization.