Comparison of Clinical Outcomes in Patients Who Underwent Bare Metal Coronary Stenting Versus Coronary By-pass Surgery

Abstract

Introduction: We aimed to compare the effects of coronary lesion complexity assessed by SYNTAX (Sx) score on the clinical outcomes in patients who have received BMS versus undergone coronary bypass grafting. Patients and Methods: Our study population consisted of 459 consecutive patients received bare metal stents (n= 265) or coronary bypass grafting (n= 294). The complexity of coronary artery disease was assessed by Sx score. Sx score was classifi ed as tertiles, as follows: low Sx score (? 22), intermediate Sx score (23-32) and high Sx score (? 33). Results: Throughout the study, the intermediate-term incidence of any revascularization was signifi cantly higher in the percutaneous coronary intervention group compared with the coronary bypass grafting group for both overall group and Sx tertiles. The intermediate-term incidence of death from any cause was comparable between the treatment groups in patients with low and intermediate Sx tertiles. However, in patients with high Sx tertile, the intermediate-term incidence of death from any cause was signifi cantly higher in percutaneous coronary intervention group compared with coronary bypass grafting group. In the overall population, adjusted [hazard ratio, 95% CI: 0.88 (0.38-2.05), p= 0.780) risks for death from any cause were consistently comparable between percutaneous coronary intervention and coronary bypass grafting, whereas adjusted [hazard ratio, 95% CI: 0.12 (0.05-0.30), p< 0.001] risks for any revascularization were consistently signifi cantly higher in the percutaneous coronary intervention group compared with coronary bypass grafting group.Conclusion: Coronary lesion complexity assessed by SYNTAX score was closely associated with the higher incidence of any revascularization and in high SYNTAX score, with higher incidence of death from any cause in patients received bare metal stents than coronary artery bypass grafting.

Keywords

• Coronary artery bypass; stents; percutaneous coronary intervention.

Koroner Baypas Cerrahisi ve Çıplak Metal Stent Uygulanan Hastaların Klinik Sonlanımlarının Karşılaştırılması

Abstract

Giriş: Biz bu çalışmamızda, koroner baypas greftleme cerrahisi ile çıplak metal stent uygulanmış hastalarda SYNTAX (Sx) skoru ile değerlendirilen koroner lezyon kompleksitelerinin klinik sonlanımlar üzerine etkisini incelemeyi amaçladık. Hastalar ve Yöntem: Çalışma grubumuz çıplak metal stent uygulanmış (n= 265) ve koroner baypas cerrahisine giden (n= 294) 459 hastadan oluşmaktadır. Koroner arter hastalığı kompleksitesi Sx skoru ile değerlendirilmiştir. Sx skoru, hafi f Sx skoru (? 22), orta Sx skoru (23-32) ve yüksek Sx skoru (? 33) olmak üzere üç gruba ayrılmıştır. Bulgular: Çalışma süresince orta dönem takipte herhangi bir nedenle revaskülarizasyon sıklığı hem tüm grupta hem de Sx alt gruplarında perkütan koroner girişim uygulanan hastalarda koroner baypas cerrahisine giden hastalara göre daha fazladır. Orta dönem takipte herhangi bir nedenden ölüm sıklığı düşük ve orta Sx gruplarında tedavi grupları arasında benzer bulunmuştur. Ancak yüksek Sx skoru grubunda orta dönem takipte herhangi bir nedenden ölüm sıklığı perkütan koroner girişim uygulanan hastalarda koroner baypas cerrahisine giden hastalara göre daha fazladır. Tüm popülasyonda herhangi bir nedenden dolayı ölüm için düzeltilmiş risk perkütan koroner girişim ve koroner baypas cerrahisi arasında benzerken [hazard ratio, %95 GA: 0.88 (0.38-2.05), p= 0.780], herhangi bir nedenle revaskülarizasyon için düzeltilmiş risk koroner baypas cerrahisi grubuna göre perkütan koroner girişim grubunda belirgin olarak daha fazlaydı [hazard ratio, %95 GA: 0.12 (0.05-0.30), p< 0.001]. Sonuç: Sx skoru ile değerlendirilen koroner lezyon kompleksitesi herhangi bir nedenle revaskülarizasyon sıklığı ile daha yakın ilişkilidir. Yüksek Sx skoru gubunda herhangi bir nedenden ölüm çıplak metal stent uygulanan hastalarda koroner baypas cerrahisine giden hastalara göre daha fazlaydı.

Keywords

• Koroner arter baypas; stentler; perkütan koroner girişim.

References

1. Silber S, Albertsson P, Aviles FF, Camici PG, Colombo A, Hamm C, et al. Guidelines for percutaneous coronary interventions. The Task Force for Percutaneous Coronary Interventions of the Euro- pean Society of Cardiology. Eur Heart J 2005;26:804-47.
2. Frutkin AD, Lindsey JB, Mehta SK, House JA, Spertus JA, Cohen DJ, et al. Drug-eluting stents and the use of percutaneous coro- nary intervention among patients with class I indications for co- ronary artery bypass surgery undergoing index revascularization: analysis from the NCDR (National Cardiovascular Data Registry). JACC Cardiovasc Interv 2009;2:614-21.
3. Suleiman MS, Hancock M, Shukla R, Rajakaruna C, Angelini GD. Cardioplegic strategies to protect the hypertrophic heart during cardiac surgery. Perfusion 2011;26(Suppl 1):48-56.
4. Elmistekawy EM, Rubens FD. Deep hypothermic circulatory ar- rest: alternative strategies for cerebral perfusion. A review article. Perfusion 2011;26(Suppl 1):27-34.
5. SoS Investigators. Coronary artery bypass surgery versus percu- taneous coronary intervention with stent implantation in patients with multivessel coronary artery disease (the stent or surgery tri- al): a randomised controlled trial. Lancet 2002;360:965-70.
6. Hueb W, Soares PR, Gersh BJ, Cesar LA, Luz PL, Puig LB, et al. The medicine, angioplasty, or surgery study (MASS-II): a rando- mized, controlled clinical trial of three therapeutic strategies for multivessel coronary artery disease: one-year results. J Am Coll Cardiol 2004;43:1743-51.
7. Rodriguez A, Bernardi V, Navia J, Baldi J, Grinfeld L, Martinez J, et al. Argentine randomized study: coronary angioplasty with stenting versus coronary bypass surgery in patients with multiple- vessel disease (ERACI II): 30-day and one-year follow-up results. ERACI II investigators. J Am Coll Cardiol 2001;37:51-8.
8. Serruys PW, Unger F, Sousa JE, Jatene A, Bonnier HJ, Schonber- ger JP, et al. Comparison of coronary-artery bypass surgery and stenting for the treatment of multivessel disease. N Engl J Med 2001;344:1117-24.

9. Hannan EL, Wu C, Walford G, Culliford AT, Gold JP, Smith CR, et al. Drug-eluting stents vs. coronary-artery bypass grafting in mul- tivessel coronary disease. N Engl J Med 2008;358:331-41.
10. Li Y, Zheng Z, Xu B, Zhang S, Li W, Gao R, et al. Comparison of drug-eluting stents and coronary artery bypass surgery for the treatment of multivessel coronary disease: three-year follow-up results from a single institution. Circulation 2009;119:2040-50.
11. Serruys PW, Morice MC, Kappetein AP, Colombo A, Holmes DR, Mack MJ, et al. Percutaneous coronary intervention versus coro- nary-artery bypass grafting for severe coronary artery disease. N Engl J Med 2009;360:961-72.
12. Park DW, Kim YH, Yun SC, Song HG, Ahn JM, Oh JH, et al. Complexity of atherosclerotic coronary artery disease and long- term outcomes in patients with unprotected left main disease tre- ated with drug-eluting stents or coronary artery bypass grafting. J Am Coll Cardiol 2011;57:2152-9.
13. Kim YH, Park DW, Kim WJ, Lee JY, Yun SC, Kang SJ, et al. Va- lidation of SYNTAX (Synergy between PCI with Taxus and Car- diac Surgery) score for prediction of outcomes after unprotected left main coronary revascularization. JACC Cardiovasc Interv 2010;3:612-23.
14. Kappetein AP, Feldman TE, Mack MJ, Morice MC, Holmes DR, Stahle E, et al. Comparison of coronary bypass surgery with drug-eluting stenting for the treatment of left main and/or three- vessel disease: 3-year follow-up of the SYNTAX trial. Eur Heart J 2011;32:2125-34.
15. Daemen J, Boersma E, Flather M, Booth J, Stables R, Rodriguez A, et al. Long-term safety and effi cacy of percutaneous coronary intervention with stenting and coronary artery bypass surgery for multivessel coronary artery disease: a meta-analysis with 5-year patient-level data from the ARTS, ERACI-II, MASS-II, and SoS tri- als. Circulation 2008;118:1146-54.
16. Hlatky MA, Boothroyd DB, Bravata DM, Boersma E, Booth J, Bro- oks MM, et al. Coronary artery bypass surgery compared with per- cutaneous coronary interventions for multivessel disease: a colla- borative analysis of individual patient data from ten randomised trials. Lancet 2009;373:1190-7.
17. Sianos G, Morel MA, Kappetein AP, Morice MC, Colombo A, Dawkins K, et al. The SYNTAX score: an angiographic tool gra- ding the complexity of coronary artery disease. Euro Intervention 2005;1:219-27.
18. Garg S, Girasis C, Sarno G, Goedhart D, Morel MA, Garcia-Gar- cia HM, et al. The SYNTAX score revisited: a reassessment of the SYNTAX score reproducibility. Catheter Cardiovasc Interv 2010;75:946-52.
19. Tanboga IH, Ekinci M, Isik T, Kurt M, Kaya A, Sevimli S. Reprodu- cibility of Syntax score: from core lab to real world. J Interv Cardiol 2011;24:302-6.
20. 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 revas- cularization for unprotected left main coronary artery stenosis. J Am Coll Cardiol 2010;55:2544-52.
21. Hannan EL, Racz MJ, Walford G, Jones RH, Ryan TJ, Bennett E, et al. Long-term outcomes of coronary-artery bypass grafting versus stent implantation. N Engl J Med 2005;352:2174-83.
22. Smith PK, Califf RM, Tuttle RH, Shaw LK, Lee KL, Delong ER, et al. Selection of surgical or percutaneous coronary interven- tion provides differential longevity benefi t. Ann Thorac Surg 2006;82:1420-8; discussion 8-9.
23. Mohr FW, Rastan AJ, Serruys PW, Kappetein AP, Holmes DR, Pomar JL, et al. Complex coronary anatomy in coronary artery bypass graft surgery: impact of complex coronary anatomy in modern bypass surgery? Lessons learned from the SYNTAX trial after two years. J Thorac Cardiovasc Surg 2011;141:130-40.
24. Carnero-Alcazar M, Maroto Castellanos LC, Silva Guisasola JA, Cobiella Carnicer J, Alswies A, Fuentes Ferrer ME, et al. SYNTAX Score is associated with worse outcomes after off-pump coronary artery bypass grafting surgery for three-vessel or left main comp- lex coronary disease. J Thorac Cardiovasc Surg 2011;142:e123- 32.